Ideal Medical Practices

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.