Ideal Medical Practices

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.

Why is it so hard to get primary care practices to change?

There is a good deal of talk about support for primary care.  That support is demonstrated in AHRQ grants targeting interventions that support independent small and medium size practices, in a blizzard of Medical Home initiatives, and more.  There is also a good deal of concern that these initiatives may prove disappointing unless we can overcome the glacial pace of change in primary and fractional improvements observed.

What can we do to accelerate primary care transformation?  Hypotheses abound.  Some point to disappointingly incremental results of the Learning Collaborative model, others to the lack of aligned payment, still others to overly broad 'change package' that fail to promote fundamental changes. 

Many things have to go right if primary care is to make the transition. 

• We need an approach that invites the participation of all kinds of practices.  Participation costs (time away from patients, travel expense, etc) must be set very low if we are going to include the full spectrum of primary care practices including solo and rural.  The Ideal Medical Practices project demonstrated one path with group learning and practice coaching by conference calls plus online resources, all tied together with a simple measurement strategy addressing the fundamental changes required.  Group learning can break out of major urban centers and meet practices closer to home.  Regional learning can be complemented with conference call and online support.
• Assistance must address the heterogeneous nature of practices.  Coaching support, peer mentoring, and improvement pathways can be nuanced to address developmental stage, baseline capacity and infrastructure, variation in population needs.  Using a measurement system based on the fundamental features of high performing primary care can identify practices in need of further assistance.
• Launch projects in supportive environments:  Teaching transformative change without aligned payment is a waste of everybody's time.  At best we can prepare participants for a future when payment will support the work, but the full work of effective primary care is ruinous in our current payment environment.  Payment aligned with the work is necessary but not sufficient: the financial incentives must flow all the way to the front lines of work. If the aligned payment dissapears into health system general funds and has no impact on staffing and support of the work in the primary care office it is a wasted effort.
• Improve the signal to noise ratio of the measurement paradigm: Flying in the face of numerous studies we have adopted a measurement system holding primary care practices accountable for outcomes for which they are sometimes only fractionally responsible.  The primary care team is not responsible for the agriculture bill supporting terrible food choices, nor is it responsible for the epidemic of obesity and our society's willingness to restrict access to health care services based on socioeconomic status.  We play a role but often not the dominant role in a diabetic person's A1c level.  Why should we beat up practices with bad quality scores when the reason the A1c is because patients can no longer afford to take their meds because they've lost their jobs?  We can and should measure practice behaviors that predict good outcome: access, relationship over time, comprehensive services, care coordination (all easily and inexpensively measured through patient experience of care).

Primary care practices want to change.  Our professional ethics are aligned with the work of effective primary care.  Change happens when the forces are aligned with the desired results.

Primary-Care and Specialists Get Their Wires Crossed - and what to do about it

What we’ve got here is a failure to communicate.

via blogs.wsj.com

"Don't you guys talk?"  Well, to be perfectly honest..... not so much, and it costs us all:

• Primary care practices spend a significant part of staff time on tracking down information from emergency departments, hospitals, and specialists, filling out forms that - if approved - would make it possible for the practice to then call to try and arrange a scan, a consultation, etc.
• Specialists are sent the wrong patient for the wrong reasons with the wrong work-up or have no information at all and a patient who has no idea why they are there.
• Patients of course suffer the most. 

A colleague of mine surveyed a high-functioning group of individuals (readers of a reputable online news service). Some of these people reported that they were receiving care from their PCP and a specialist. 

Asked "Do you know who is in charge?", 25% said "No."  Those 25% were twice as likely to report having been hospitalized within the past year.

This striking correlation has a number of possible explanations.  One possible explanation is that we in the health care system are operating in silos and are put the people we serve at risk when we fail to communicate well across those silos.  This explanation has some face validity since poor communication and lack of coordination is a near-universal experience.

What can we do about this?

1. Require seamless communication across health information technology platforms.  The rules we have in place are either inadequate or inadequately enforced.  Right now we have lip service commitment to cross-platform communication but systems almost never communicate well and the cost of bridging the gaps is completely out of reach of the average practice.
2. Require insurers to pay for care coordination by primary care.  The evidence supporting good care coordination abounds yet practices receive only lip service - requests to do more without the means to do the work.  Primary care is the weakest part of our health care system because we have systematically starved it beyond its ability to perform the basic functions of primary care.  "Help" that stipulates "do this extra work and we'll consider maybe paying you in the future if you get those pigs to fly" is a non-starter.
3. Make 'patient experience of care coordination' a core quality metric.  We over-emphasize relative trivia while mostly ignoring the core functions of primary care.  This distracts the national conversation, the work of practice transformation, and new payment models with lower impact work while fundamental benefits to the public are ignored. We don't have to give up measuring 'the percent of diabetics who have had monofilament foot exams', but we should focus first on a core set of primary care measures addressing the core features of primary care:  access, relationship over time, comprehensive services, and care coordination.

Transforming our health care system so that we may achieve better outcomes at lower per capita costs will take monumental effort.  That effort should focus first on the most important aspects of our current failures - the ones that have the greatest possible benefit for the widest number of people.

Supporting primary care transformation does just that - but only if the transformation addresses the fundamental attributes of primary care.

Physician Groups Use of Data from Patient Experience Surveys

Patient reported experience of care can be accurately measured and can identify important aspects of practice performance.(1)  Patients who report good experience with key attributes are more likely to have good outcomes and cost the health system less.(2)  Key attributes include: good access to care, good communication, support for self-management, good continuity, care coordination.

I love that we're seeing patient experience in more publications but I'm a bit perplexed by this article:

M. W. Friedberg, G. K. SteelFisher, M. Karp et al., "Physician Groups' Use of Data from Patient Experience Surveys," Journal of General Internal Medicine, published online Dec. 17, 2010.

It is an interesting observational study looking at how physician groups in Massachusetts used patient experience data to inform quality improvement.

The study tells us that financial incentives for patient experience measures predicts work on patient experience.  No surprise, but it is good to confirm widely held belief in studies.

The summarizing conclusion seems to be a circular arguement.  Here's the statement:

Groups with more integrated organizational models were especially likely to engage in group-wide improvement efforts, and all groups facing financial incentives based on patient experience reported improvement efforts of some kind.

Here's the authors' definition of integrated organizational models:

For this study, integrated medical groups were defined as those in which most decisions about policies, staffing, and resources were made by a group manager or management team.

So the authors have concluded that group wide activity is predicted by having an organization with a group leader.

Should we push independent or loosely affiliated groups into 'integrated' groups with central control?  I don't think we can make the call based on this study.  Community Care of North Carolina succeeds in improved population outcomes without resorting to centralized practice administration.

We mustn't mistake the means with the end.  The goal is improved outcomes and bending the cost curve, it is not 'centralized administration of practices' unless and until we have definitive studies linking centralized administration with improved outcomes.

(1) Safran DG. Defining the future of primary care: what can we learn from patients? Ann Intern Med. 2003;138:248–55.

(2) 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.

Building a high performing medical neighborhood - better care, better outcomes

Rich Keller from Treo Solutions has an interesting post.  He's talking to health plans about why it might be in their best interest to support high performing local medical neighborhoods. 

I've worked as a solo physician and in a big group.  No matter the setting, I always worked as part of a larger team - coordinating the care of those whose needs exceeded the comprehensive services our practice had to offer.  Our teamlet (RN and I) preferred to work with wider team members who: communicated clearly and in a timely manner, provided a clear and convincing rationale for doing procedures that might put our patients at risk, provided timely access.

The relationship we had with the wider team was fostered in part by our willingness to provide good information, do the right work-up in advance, and generally to refer the right type of cases. We did not have this type of relationship with all the specialists and other providers in our community; some we preferred to avoid, others were just less well known. This group of better-known specialists is the 'medical neighborhood.'  We built these relationships over time and solidified them through trust built on repeated good experience.

I can site for my patients published examples of the benefits to patients of good collaborative care between PCP and specialist, examples of benefits when there is good communication and choice of specialists who don't consider my patient referral as license to use every device and procedure likely to generate revenue.*

If I want to build an Accountable Care Organization to better care for a population of people, I would only consider doing so with my team, my neighborhood, the group with whom I have built trust over the years.  When patients ask to be referred outside my trusted group I am willing to do so, but I explain the risks and benefits of working with specialists I do not know: the care might be terrific or they might be exposed to unnecessary testing and procedures that put them at risk of unnecessary complications and harm.

*Zastrow RJ, Quadracci L.  Engaging Quad/Graphics Employees in the Improvement of Their Health and Healthcare Journal of Ambulatory Care Management, 2006 29(3), 227-231

Fuhrmans, V.  Radical Surgery -- One Cure for High Health Costs: In-House Clinics at Companies Wisconsin Firm Saves Money By Hiring Its Own Doctors
Patients Get More Time, The Wall Street Journal, Feb 11, 2005

This is the best of times and worst of times for solo and small medical practices

We're living in interesting times for primary care.  There is widespread recognition that effective primary care is the foundation of any high performing health system and there are a number of programs in the works to better support primary care (best of times).  Even though solo and small practices make up more than 60% of practices in the US there are continued calls to force them out of existence and numerous policies and initiatives aimed at helping primary care that threaten the survival of independent practices (worst of times).

I give you two anecdotes.

"Time to pack it in"

Well Folks the time has finally come upon us.... We have been pretty broke and just sort of attempting to ride out the insane wave of what was a perfect storm in our personal lives with family illness and being more than just a bit over whelmed with all of that, two kids, a crumbing school district, a crumbing healthcare system that wants us to work for peanuts if not even for free while constantly increasing its demands upon us for more BS busy work, reviews, prior auths, you all know the drill....

This has been a tough decade and many of my primary care colleagues in solo and small practices are wondering if 2011 is the year that will finally force them to close their practices.  They love their patients, love their profession, but are struggling to survive in a toxic health care payment and policy environment.

• There has been a steady increase in unfunded work of prior authorizations, permissions, restrictions on what they can do for their patients.
• Initiatives aimed at supporting primary care are biased in favor of large institutions that flex their negotiating muscle to land higher fees, a guaranteed place at every policy table.
• Measurement strategies built on assumptions that embrace burdensome peripheral detail while ignoring the foundation of high performing primary care.
• Payers unwilling or too afraid to shift funding to support effective primary care.  That funding is the missing ingredient in redesigning our delivery system to achieve better outcomes at lower cost.

"A glimmer of hope"

...I am also relatively certain 2011 will be my best year financially as I finish paying off the last of the practice debt, there is the meaningful use funds, and I believe as the economy gets better, patients will again find their way to my door. Aside from the economics, I look forward to launching my new website, adding a patient portal, pushing the envelope at the state level, and watching/helping  this movement of wonderful, heroic docs continue to grow and develop.
So tomorrow night I will toast both the fact my practice made it through another difficult year and the hope that this was the last difficult year I will have to make it through. I will also toast my fellow IMPs, whose continued words of wisdom and assistance have kept my practice efficient, my mind challenged and my heart optimistic. Thanks to one and all.
Have a wonderful, happy, healthy, safe and prosperous New Year.
John Brady MD  The Village Doctor Newport News VA

I'm hearing an increased level of interest in supporting solo and small practices in the US.  I've been reading an AHRQ RFP that is aimed directly at developing support for independent small practices.  The interest is real, the need is real.  2011 will tell us if the support is real.

Real support can be demonstrated by:

• Protecting independent practices from anti-trust allegations so that they may work together to improve quality.
• Provide cost effective technical assistance in a way that invites independent and small practice participation (e.g. by using techniques we found effective in the Ideal Medical Practices project).
• Use a measurement approach that provides meaningful data to individual clinicians on the core attributes of primary care while reducing the burden of measurement (e.g. the patient experience data set from HowsYourHealth.org).
• Reward participation, improvement and attainment in programs that lead to improved population health, experience of care, and in so doing bends the cost curve.
• Align the payment system with the work of effective primary care (e.g. care coordination payments, case or episode payments, partial capitation, almost anything that balances against the toxic nature of our RBRVS FFS pay-for-volume-regardless-of-quality system)

Primary care is stretched too thin to do this and prove the results before finances are shifted to support the work.  Real funding for real work is a non-negotiable starting point.  Medical literature supports both the improved quality and reduced total costs that come from doing this work well.  Practices of all sizes can and should be held accountable to performance standards on the core set of primary care functions.

Changes in payment means reducing payment elsewhere, so this will take guts, but give the dire nature of state budgets I suspect that 2011 and 2012 will provide the intestinal fortitude to at least pilot real innovation that truly supports excellent primary care in exchange for reduced per-capita cost trends.