Category Archives: Clinician-Patient Relationships

Healthcare Turkey Talk

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Thanksgiving is a great occasion for learning what people think about the future of the US healthcare system.*  This year, I’m going to find out what people are thinking about some of the coming health delivery system changes – particularly Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMH).

I’ve conducted this two-question informal survey with handfuls of people and found their level of knowledge and positive reactions equivalent to Congress’s approval rating, i.e. 9%.  This is worrisome, since if transforming the US healthcare system to increase value and quality will be partially based on ACOs’ and PCMHs’ superior care coordinating abilities, it will be hard to improve cost, quality, and access at the local level if the average person/patient doesn’t know what these organization are, there is inherent aversion to their names, or there is resistant to unexplained “changes.” (For example, several people I’ve talked to have thought Accountable Care Organizations seem like HMOs, and Patient-Centered Medical Homes are home care, nursing homes or hospice.)

So fair readers of this blog, let me know what you hear at your Turkey dinners and associated holiday events – and I’ll post back next week what I heard from my disparate and decidedly unrestrained friends and relatives.

 

*Unlike most meals and gathering of family and friends, Thanksgiving dinner goes on for a long time, there are no ceremonial interludes, and it is generally a sit-down affair so you can’t move on to someone else – or out the door. This means “Aunt Sally” can pull your ear or kick your leg (either figuratively or literally) for upwards of 2 hours about what’s wrong with the US healthcare system and what how to fix it.  My advice is to ask questions to find out root concerns and to gauge people’s understanding of the coming ACA changes in both healthcare delivery and insurance coverage.  Also, if you find yourself referring to a recent study from Commonwealth or Kaiser Family Foundation, (or a similar organization or government group), STOP, put food in your mouth and nod encouragement for them to keep talking, because quoting the best studies to someone impassioned about their healthcare will be about as successful as convincing your 7-year-old cousin that 3.14159 is a great dessert.

Smoking is So Bad For You That……..It Makes Me Sick

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The evidence for the ill effects of smoking keeps getting stronger and scarier.  If one were to construct a balance sheet of tobacco’s pros and cons it would look much worse than the one Bernie Madoff was hiding from his investors and the SEC.

Making the Risk of Smoking Personal

I was recently talking with one of my IT consultants and we started discussing tobacco use since he thought his smoking might have been one reason he’d been denied health insurance. What he – and many people – don’t realize is that the major health risk from smoking is not lung cancer, but how damaging it is to the heart and blood vessels, i.e., your cardiovascular system:

  • On Monday USA Today reported on a study showing that smoking cigarettes doubles a person’s risk of stroke.
  • Studies have shown that second-hand smoke increases the risk of heart attacks – which is why many states and even the country of Ireland have prohibited smoking in bars and restaurants.
  • When Ireland banned smoking in pubs the rate of hospital admissions for heart attacks dropped by more than 10% in the following year.

Additional evidence about the risks of smoking is pervasive – sort of like finding a piece of hay in a bale of hay – including a report from the US Surgeon General indicating that smoking ONE CIGARETTE can increase the risk of heart disease as well as cancer. In scientific terminology this means that there is no lower limit or threshold below which tobacco causes no harm.

Similarly, the concept that tobacco in forms other than cigarettes aren’t so bad is, well BS: cigars and “chewing tobacco” are bad for you too – just in different ways depending on how they are used and how often. And the propaganda that hookahs (smoking flavored tobacco through a water pipe) are safe is hooey – smoking a hookah for an hour can be like smoking ONE HUNDRED (100) cigarettes.

So after going through these facts to help my IT consultant put smoking cigarettes into perspective, (i.e., tobacco damages your heart and blood vessels etc.) – and adding a few points about how smoking increases a person’s risk for dementia, Alzheimer’s, other cancers besides lung cancer, and sexual dysfunction – I prioritizing the bad things he could possibly be doing to himself:

  1. Crystal Meth - which rewires your brain in very bad ways that are hard or impossible to reverse
  2. Heroin
  3. Having unprotected sex with multiple IV drug abusers
  4. Smoking cigarettes…. or using any form of tobacco

The Positive Attributes of Tobacco

The positive side of tobacco’s “balance sheet” is pretty slim:

  • Income for tobacco farmers
  • Income for companies that make and sell cigarettes and other tobacco products
  • There are a few rare conditions where nicotine may help prevent flare-ups
  • It’s “cool” and it makes people appear older. (Smoking actually does make people look older by causing skin changes on the hands and face, including wrinkles that can make a 35-year-old smoker look 45 or 50.)

Bottom Line

So adding this all up into a Bernie Madoff-type balance sheet it seems that smoking cigarettes is like:

  • Driving without a seat belt – and twenty bowling balls and big pieces of broken glass in your passenger seat
  • Sleeping with a loaded gun in the waistband of your pajamas
  • Scuba diving or flying an airplane without lessons
  • Riding a motorcycle while juggling

Like smoking, there will be people who might be able to do these things for years without ever developing a “problem.” But I suspect that most smokers don’t understand the real risks they are taking, and certainly wouldn’t take similar risks for themselves or their children by doing other things like replacing their smoke detectors with oil lamps.

And lastly, I believe healthcare professionals are not doing enough to help people stop smoking.  Kicking the nicotine addiction isn’t easy, but there are ways to help: counseling, support groups, prescription and OTC medications, and even financial incentives from health insurers and employer including higher (or lower) insurance premiums.  As an additional incentive, some companies are not hiring people who smoke - although some states have passed laws protecting smokers’ off-duty “rights” to such self-injurious conduct. So unless you’re living in an alternative universe where the job market is “smoking,” putting yourself at a disadvantage for getting a job (or a better job) because you smoke doesn’t seem like a very good career move. It might be better to have committed felony financial fraud since at least that demonstrates some math skills and not just the ability to suck in poisons.

Patient-Centered Care? Or Not?

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The term “patient-centered care” has increasingly been used to describe healthcare structures that deliver better quality care – as well as often doing so with lower costs.  And today there was a news story about how some medical schools are assessing applicants’ interpersonal skills, something that is fundamental for being a patient-centric clinician.

While there are have been numerous articles demonstrating the value of patient-centered care and concluding that it is better and should be promoted – including those looking at the ill named “Patient-Centered Medical Homes” – I’ve found myself pondering the following questions:

“What type of care have clinicians been providing if it hasn’t been patient-centered? Has it been clinician/physician centered? Or revenue centered? Or just intentionally confusing and impersonal care designed to stymie the adoption of evidence based standards of care?”

“And along those lines, is the widespread delivery of non-patient-centered care the reason why the IOM concluded that it takes about 17 years for valuable healthcare information to be adopted into clinical practice? Or why Atul Gawande found that hospitals in other countries have widely adopted surgical checklists to reduce medical errors and adverse outcomes, while only 25% of US hospitals are using these checklists?”

I’m just asking….

Medical Homes (PCMH) in 2011 – Patient and Consumer Centric

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Patient-Centered Medical Homes (PCMH) are continuing to be a bigger and broader part of the real-world discussions about health reform and transformation in the US. According to the the National Committee for Quality Assurance (NCQA) at the end of 2010 there were 7,676 clinicians in 1,506 recognized PCMH practices in the US. This information was released last week by NCQA with their updated 2011 PCMH Standards.

Patient Centered Medical Homes 2010

Another marker of medical homes’ increasing pervasiveness is the blurb – “Home sweet medical home” – in the March 2011 issue of Consumer Reports magazine that starts with, “If you haven’t already heard the term ‘patient-centered medical home,’ chances are you will soon.”

Consumer Reports – “Home Sweet Medical Home”
The Consumer Reports blurb is part of an article about what primary care physicians wish their patients knew. Interestingly this longish blurb notes that any practice can be more patient-centric without being officially certified, and it lists the important features patients should look for:

  1. Can you get an urgent appointment within 24 hours?
  2. Can you reach somebody in the practice by phone at night or on weekends?
  3. Can you get test results quickly via e-mail or telephone, or on-line?
  4. If you have a chronic condition, is there a system for tracking how you’re doing?
  5. Does the practice include non-MD staff members such as nutritionists or nurse practitioners to help you manage your medications or chronic conditions?
  6. Does your primary-care doctor keep track of your treatment by specialists?

NCQA’s 2011 PCMH Recognition Standards, Elements, and Factors
The 2011 PCMH Standards NCQA released last week are much more detailed about what a primary care practice should look like to provide high quality primary care – and they are a logical evolution from their 2008 Standards. Specifically they:

  • Reduce the number of Standards from 9 to 6 – which should make them easier to understand and implement.
    • The 6 Standards have multiple Elements. And each Element has various Factors that contribute to the scoring for that Element.
  • Integrate newer health IT standards and requirements.
    • NCQA provides a cross-walk between the Elements and the corresponding Federal Meaningful Use requirements for health IT that enable clinicians to receive higher Medicare and Medicaid reimbursements.
  • Include a patient survey, which will be available in 2012.
    • The optional survey will provide more patient-centric feedback about people’s experiences and  enable practices to score extra points towards the recognition Tiers.

NCQA also continues to have three Tiers of possible recognition – with Tier 3 being the highest.The new NCQA standards also continue to have “Must-Pass” Elements (in bold/italics below) for the 6 Standards. And practices must score at at least 50% on all those Elements to receive any recognition Tier.

Standard 1: Enhance Access and Continuity
Access During Office Hours, e.g., same day appointments and telephone or email communications

Standard 2: Identify and Manage Patient Populations
Use Data for Population Management, e.g., using medical record data to remind patients about getting evidence-based care for specific preventive services and treatments for chronic conditions

Standard 3: Plan and Manage Care
Care Management, e.g., individually written care plans and addressing barriers to patients achieving their treatment goals

Standard 4: Provide Self-Care and Community Support
Support Self-Care Process, e.g., providing educational resources and tools to enable patients to improve their self-care and healthy lifestyles/behaviors

Standard 5: Track and Coordinate Care
Referral Tracking and Follow-Up, e.g., coordinating and following-up on referrals to specialists, including testing done by specialists and their recommended treatments

Standard 6: Measure and Improve Performance
Implement Continuous Quality Improvement, e.g., setting goals and acting to improve care for patients with chronic conditions, (such as diabetes, heart disease and depression), and preventive services, (such as immunizations, and cancer and osteoporosis screening)

It is also worth noting that among the various Factors that make up the Elements, NCQA designate some as “Critical Factors,” i.e., they are required for any scoring on that Element.  And two of these Critical Factors are for Must-Pass Elements:

  • “Providing same-day appointments”
  • “Develops and documents self-management plans and goals in collaboration with at least 50% of patients/families”

Thus, to achieve any level of recognition as a PCMH from NCQA, practices must have these two capabilities.

Conclusions:
While it may be coincidental that Consumer Reports lists 6 criteria for patients to consider in evaluating primary care practices for their “medical homeness,” and NCQA has 6 Must-Pass Elements, the two lists do parallel each other.

NCQA and Consumer Reports are targeting different groups of stakeholders – which is appropriate. NCQA’s requirements enable practices and providers to become recognized, while also informing payers and regulators so they can determine how to utilize a practice’s recognition in their policies and practices – including reimbursement levels.

Similarly, Consumer Reports is seeking to educate consumers, (a.k.a. patients and families). What is reassuring is that Consumers Reports doesn’t try to compare medical homes or clinics using its normal format of tables of numbers and those great red and black circle symbols.  That type of evaluation works well for commodities like TVs, but medical care is a process not a product, and it needs to be individualized for the patient – so what is a good medical home for one person may not be as appropriate for another.  (Atul Gawande’s recent New Yorker article “Hot Spotter” includes some examples of how cultural appropriateness can be a determining factor for the success of care for severely ill people.)

NCQA’s standards focus on structures and processes, and thus are not the beginning and end of what is needed for a successful patient-centered medical home. But certainly rigorous structural and process standards, combined with consumer education – along with other contributing drivers like cultural change motivators and incentives for achieving better outcomes – should lead to better quality, value, and efficiency in our health care system.

Let me know what you think about Medical Homes.

[Full Disclosure: I was given the Consumer Reports magazine by a friend who bought it because it has an article about TVs - and now I have to help her go buy a TV.]

Doctors Communications to Patient’s Family

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The great writer John McPhee’s article in the February 8th issue of the New Yorker is primarily about his experiences fishing for pickerel in New Hampshire, but the subtext is his connecting to his dying father who is in the hospital after a severe stroke.

While the article is extremely warm and heart-felt, two short sections stand out because of his visceral reaction to his father’s doctor:

“His room had a south-facing window.  My mother, in a flood of light, eighty-seven, looked even smaller than she was, and space was limited around her, with me, my brother, my sister and a young doctor together beside the bed. I was startled by the candor of the doctor.  He said the patient did not have many days to live, and he described cerebral events in language only the patient, among those present, was equipped to understand.  But the patient did not understand: ‘He can’t comprehend anything, his eyes follow nothing, he is finished,’ the doctor said, and we should prepare ourselves.

“Wordlessly, I said to him, ‘You fucking bastard.’ My father may not have been comprehending, but my mother was right there before him, and his words, like everything else in those hours, were falling upon her and dripping away like rain.  Nor did he stop. There was more of the same, until he finally excused himself to continue on his rounds.”
……
“The young doctor returned, twenty-four hours exactly after his earlier visit. He touched the patient with his fingers and steel, and qualified for compensation. [emphasis added] He said there had been no change and not to expect any; the patient’s comprehension would not improve. He went on as had the day before.  My father, across the years, had always seemed incapable of speaking critically of another doctor, perhaps in a paradoxical way, because he had been present in the operating room where the mistake of another doctor had ended his mother’s life. Even-tempered as he generally appeared to be, my father could blow his top, and I wondered, with respect to his profession, to what extent this situation would be testing him he were able to listen, comprehend, and speak.”

To be fair – and maybe overly fair – perhaps the physician taking care of Dr. McPhee was focused on the outcome of his patient, and realizing that improvement would not happen wanted to set realistic expectations for the family. However, what is clear from John McPhee’s prose is that the physician didn’t see the patient’s family within his care continuum.  He didn’t treat them as if they were his patients who needed his compassion.  If he had, he might have realized that while he – and medical science – could do very little for Dr. McPhee after his stroke, there was a lot that he could do for the family by being more compassionate and empathetic in his interactions as he was explaining the diagnosis and prognosis.

In addition – although John McPhee doesn’t mention it in his article – hopefully there were other components of the care team besides the one physician, since a well-coordinated care team should provide additional information and support to the family.  It would be unrealistic for a single physician to provide all the information and support to a critically ill patient and their family – even when there is no hope and no interventions to ease the patient’s condition. Expecting a physician to do all this alone is like asking an NBA basketball player to go 1 on 5 against another team.  Even the greats of Chamberlain,  Jordan, or Bryant wouldn’t have been able to do that.

I applaud John McPhee for his great writing and for including his direct feelings about his encounter with the medical care system.  His article would be good reading for clinicians in training and practice since it so deeply illuminates how patients and their families can view clinicians, their words, and how they deliver them. Similarly, his article would be a great reading for students and policy makers interested in the relationships and communications between clinicians and patients – and their families – as well as for those interested in improving compassionate caregiving.

Thanksgiving Conversations About Health – Engage With Grace Blog Rally

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For many years I’ve used the Thanksgiving dinner table conversation as a model for discussions about healthcare – but usually I’ve put it in the context of people who work for healthcare companies, (e.g. pharmaceutical or managed care), trying to address, rebuff and rebut the criticisms they might get from family members, (e.g. Aunt Lilly), about the problems with the US healthcare system and the actions or positions of various companies or industries.  However, last year – and again this year – several bloggers have been cooperating to promote Thanksgiving weekend discussions about end of life care issues.  This effort has been called the Engage with Grace, and last year it was a great success, with over 100 bloggers participating.

The original mission of this “blog rally” was to get more and more people talking about their end of life wishes. But because this year has had quite intensive public debate about health reform, the decision was made for this year to do something a bit different and add a bit of levity to the efforts to promote discussions.

At the heart of Engage With Grace are five questions designed to get the conversation started, but to put a slightly lighter spin on these questions, the first set below has a less serious tone – the “real” Engage With Grace questions are at the end of this post – and I’ve interjected five other humorous ones in between. They’re not easy questions, but they are important – and the goal of both the serious and lighter questions are to get people talking, since if you can’t talk about the funny questions, then how can families and friends expect to seriously talk about the difficult and important ones?

Engage With Grace Questions - Set 1

  1. Which one of your family members would you trade for a celebrity or professional athlete, and who would you trade them for?
  2. After you made that trade, would you want the celebrity or professional athlete to cook or do the dishes at your holiday meal?
  3. Would you want that celebrity or professional athlete to be on your post holiday meal team for Charades or Monopoly?
  4. Would you want that celebrity or professional athlete to be named on your advanced directive or living will so they could make decisions about your healthcare needs and choices if you were unable to do so?
  5. Would you want that celebrity or professional athlete to represent you in the US Congress to make decisions about Medicare and health reform?

Engage With Grace Questions - Set 2

Have a good holiday season – and go with grace.

Encouraging Communications About Patients’ Goals

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I attended a great event yesterday where experts discussed how to improve healthcare quality and safety by increasing patients’ involvement in making healthcare decisions.

This seminar, “Patient-Centeredness and Patient Safety: How Are They Interconnected,” was organized by the Kenneth B. Schwartz Center and sponsored by the Massachusetts Medical Society and CRICO/RMF.  Don Berwick (President & CEO of the Institute for Healthcare Improvement) was the main speaker followed by a panel consisting of two patient safety leaders from local hospitals and a patient involved with promoting patient engagement in quality improvement.

To start the event, Dr. Berwick discussed how his thinking about healthcare quality had evolved over several decades, and his increasing belief in the importance of patient involvement. He discussed his Health Affairs article on Patient-Centered care, and summarized his current thinking about how to design patient-centered care in 8 bullets:

  1. Place the patient at the center
  2. Individualize
  3. Welcome family and loved ones
  4. Maximize health influences within care
  5. Maximize health influences outside of care
  6. Rely on sophisticated, disciplined evidence
  7. Use all relevant capabilities – waste nothing
  8. Connect helping influences with each other

Communications Is Crucial for Achieving Patient-Centerdness and Goal Sharing
The essence of the panel’s discussion was about how to improve communications among patients and their clinicians so that each others’ goals were shared and understood.  One example raised by a panelist was initiatives to prevent patients from falling in the hospital.  Patients may see nurses being in bathrooms with them as intrusive or uncomfortable, but discussing their shared goal of not having patients fall and hurt themselves shifts the context of the nurse’s action and enables it to be embraced by the patient rather than resisted.

From the patient’s perspective too often clinicians may have their own ideas about what the goals of the treatment should be, but without understanding the patient’s life interests and goals the two may be disconnected.  For example, clinicians often ask patients what they do for work to understand if the treatment or the outcomes will be compatible with their jobs, but often patient’s happiness or life fulfillment is related to something outside of work, such as playing the piano, playing with grandchildren, rollerblading, hiking with their dogs in the mountains, or hang-gliding.  Treating a patient’s injury or illness so they can do (or be able to try to do) those activities may be very different than what would be indicated if the goal was to enable them to work in an office.

Creating Policies to Promote Communications and Goal Sharing
Dr. Berwick’s presentation also included a brief discussion of how evidence based medicine (EBM) can improve patient safety by avoiding unnecessary care and setting realistic expectations about the outcomes for chosen treatments.  This is captured in his 6th bullet above. One of the challenges in the current push towards more EBM – and comparative effectiveness research (CER) – is what to actually measure in this research. Combining the health system’s desire for optimal outcomes with patient-centeredness, (i.e., his 2nd bullet – “Individualize”), could be achieved by including the patient’s goals for their treatment as one of the outcomes measured in EBM and CER programs.

Benefits of Measuring Achievement of Patients’ Goals as an “Outcome”
Process measures, (such as percentage of patients who’ve received a recommended treatment), are usually easier to evaluate, but are really proxies for clinical outcomes.  Actual outcomes like mortality or hospitalization can be harder to evaluate, in part because of individual patient differences and thus the raw data needs to be risk adjusted. However, measuring achievement of the patient’s goals could be very important and valuable to add to these evaluations – and could be a rough way to inherently risk adjust the data, i.e. the “goals” of treating a broken hip may be different for a 50 year old person than someone who is 70.  The actual measurement of such goal achievement could be done based upon answering the question of “how well were the patient’s goals met?”  Clearly this would have to be quantified in some way – and perhaps that could be done by the patients themselves on an 11 point scale from 0-100%.

Not only would measuring this “patient goal achievement” outcome add a useful dimension to some research, but it would also put the question of “what are the patient’s goals?” right at the front of the patient-clinician conversation.  And in the context of health reform and system improvement, by using the dictum of, “we manage what we measure,” measuring how well delivery systems and clinicians are achieving patients’ goals could be an important force for transforming care delivery.

Bottom Line for Patients and Clinicians
The next time you’re a patient talking to a clinician, be sure to talk about your goals for treating whatever ailment caused you to see that clinician.  And clinicians need to tell their patients what goals they expect to achieve from the treatment they’re recommending.  This is the start of a conversation since the patient’s expectations may not be realistic – such as for a patient with a severe fracture who wants to run a marathon in three weeks.  But by understanding each others goals and expectations they can agree on what should be done and how to proceed.

Need for Continuity of Care and Primary Care Clinicians
Of course some patients may seek to “doctor shop” looking for a clinician who will promise to achieve their goals.  This can be good if the first clinician isn’t attuned to the patient’s wishes, but it can also be bad if the patient’s expectations are unrealistic.  That is why having a trusted relationship with a primary care clinician can be so important, since their PCC can help them evaluate and digest other clinicians’ recommendations.  Again, it comes down to ongoing and two-way communications to understand goals and jointly develop treatment plans and decisions.

Communicating with Clinicians to Improve Quality

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At a recent public forum on improving quality and value in healthcare, an audience member asked how can patients know if the treatment or diagnostic test their clinician is recommending is really the best thing for them.  This reminded me that the Agency for Healthcare Research and Policy (AHRQ), recently ppublished a two page tip sheet to help patients talk to their doctors and a web-page that helps people create a set of questions customized for their individual healthcare needs and situations.

While these are obviously useful tools, I realized that emphasizing patient-clinician communications is now more important than ever because of the growing trend toward “consumer directed healthcare” and “patient empowerment.”  While these types of activities and insurance product may be able to reduce costs by incentivizing people to use less healthcare, how they effect quality is still uncertain.  In addition, the enormous amount information available on the internet is making people well armed with data and facts, but not necessarily with knowledge.  Even with a lot of facts and data, patients are much better off having another person, (i.e., a trained clinician), integrate all the information about their individual situation and present a complete perspective and set of recommendations.  (This is why it is generally not appropriate for physicians to treat themselves or family members, i.e. because they cannot be both the patient – or family member – and provide an impartial and objective analysis.)

Asking Questions is Key for Communications and Quality Improvement
The AHRQ materials are valuable for improving the quality of care because patients may find themselves overwhelmed in a medical office, and forget to ask the right questions – particularly when faced with a new diagnosis or presented with a set of recommendations for treatment of an existing condition.  Coming to the medical office with a set of written questions will help remind the patient what questions they want to ask, and help promote a conversation with the clinician about the patient’s needs and desires. Clinicians are generally much more receptive to patients who ask questions than to those who just present opinions, requests, or demands about their treatment.

AHRQ’s “Talking with Your Doctor” tip sheet, has two key messages for both policy makers and patients:

  • Research has shown that patients who have good relationships with their doctors tend to be more satisfied with their care – and to have better results.
  • Write down your questions before your visit. List the most important ones first to make sure they get asked and answered.

Checking for the Checklist
AHRQ’s web-page for creating customized question lists is a valuable resource not just for preparing to talk with clinicians, but also for choosing health plans, hospitals, long-term care facilities – as well as clinicians.  While the list of suggested questions AHRQ is good, one item that I’d add is, “Does the hospital require the use of surgical checklists?”  (FYI – I’ve written about how such checklists have been shown to reduce errors and improve quality, and I’ve suggested that patients ask their surgeons and hospitals if they use them – and if not, why not?)

And apparently I’m not alone in promoting greater use of checklists in hospitals.  I recently heard that Health Care for All here in Massachusetts is pushing for legislation to require hospitals to use such checklists.  I applaud their efforts to highlight this quality improving measure, but also want to note that there are arguments on both sides for whether legislation is the best route to improve quality of care at all hospitals.  For example, how specific do we want laws to be in listing what hospitals and doctors are required to do, since laws can be difficult and time consumer to change?  Conversely, how quickly and completely will hospitals and doctors change their practices if they are not compelled to do so by new laws? And are their other mechanisms besides laws to make these changes faster and more completely?

Questions are the Answer
Whatever routes are used to improve quality of healthcare, (e.g. legislation, patient empowerment, financial incentive, peer pressure, etc.), it’s clear that patients, advocates, policy makers, and others need to continue asking thoughtful and focused questions.  As the website name for AHRQ’s customized questions list states, “Questions are the Answer.”

Medical Case Management – Making It Work

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Jeffrey Krasner had a great article in yesterday’s Boston Globe about his experience trying to manage and coordinate his Mom’s care.  As a very experienced health reporter in a city dense with advanced health care delivery and health policy wonks, his story of problems getting care coordinated amongst her physicians and having her medical records transferred is very illuminating.  However, for those of us who have spent time trying to help friends and relatives navigate the medical care maze, it is not surprising.  (I went through a somewhat similar situation with my Aunt several years ago.)

While some people conclude that the solution to this complexity is a national health system, I believe that creating more standardization and accountability within our existing structure is a much more practical answer.  Significant steps have already occurred in that direction in hospital care with checklists for pre and post surgical review, and steps for inserting IV lines into central veins.  And of course the Institute for Healthcare Improvement has done tremendous work to improve the quality of care in hospitals across the country with arrays of sophisticated process improvements.

Making Care Coordination Work in the Outpatient World
The challenge is taking the lessons learned from these experiences and successfully implementing them in outpatient settings such as physicians’ offices – which are much more diverse and resource poor. One way to facilitate quality improvement and better care management would be to increase the integration and consolidation of physicians into larger groups, since it has been shown that larger groups are more likely to be able to provide care coordination and management services to their patients.

These concepts are being defined more and more as part of the Medical Home model – which many medical and policy groups are increasingly supporting, (such as the ACP, AAFP, AOA, APA, MedPAC and the Commonwealth Fund), and which I have written about previously.  While evidence is still being gathered about how well Medical Homes are performing, and how they should best be structured, consensus is building that they are a practical concept for improving the quality of care,  controlling costs, and increasing accountability for the delivery of care.  In addition, because of how Medical Homes can place shared responsibility on physicians and patients, and can make providers accountable for clinical and cost outcomes, they should benefit and be supported by patients, physicians, payers and others.  And having that many stakeholders supporting any idea is a huge first step towards making significant changes.  Of course, making sure that all stakeholders understand what the Medical Home concept means, and how to practically and effectively build and use them, will also be necessary for making them successful.

Patient-Physician Communications: Sometimes It’s the Small Things

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Wide ranging discussions are ongoing about how to systemically improve the collection and analysis of clinical information via electronic medical records and other forms of health IT.  In addition there are more focused discussions about how to improve physician patient relationships.  However, when a friend told me how a communication failure with her physician left her with less than optimal treatment instructions, I was reminded that at the very micro level there are additional communications issues that need to be examined.

Here’s the story:  My friend had a temporary and rather minor – but certainly annoying -  skin problem, and her doctor advised her that hot/moist compresses would be the best thing, and that she should wrap a potato in a paper towel and “zap it,” and then apply this to where she had the skin issue.  The problem is that my friend doesn’t have a microwave – which is presumably what her physician meant by “zap it,” – and my friend, who is a university professor, didn’t want to get into a discussion about why she doesn’t have a microwave at home.  (It’s because she’s an old school cook.)  So rather than ask about other options, etc., she just let it go and left with advice that she couldn’t really use. (Yes, she understood hot/moist compress, but what the potato has more mass which stays hot and moist longer than just a washcloth or paper towels – and my friend is a social scientist not a physicist.)

Now, I realize that there are other ways to make a hot/moist compress and to heat a potato,  (which I discussed with my friend), but this simple situation illustrates the need for individualized care and full communications between the physician and their patient.  For example, if my friend had been homeless or living in a shelter, would the physician then recognized that she might not have access to a microwave or a potato?  Probably so, but it still leads back to the conclusion that asking patients if they have any questions about what they are supposed to do to treat their ailments – or to even have them repeat back the instructions – and ask them if there are anything in the instructions that they might have trouble doing, are important for physicians to consider doing.  Will this take more time?  Yes.  Will it help ensure that patients are actually getting the “treatments” that they should?  Yes.  It is really any different that asking patients if they can afford to buy a prescription medicine or checking to make sure that the specific medicine is on their health insurer’s formulary? No.

These are factors in delivering quality healthcare that can only partially be addressed with technology, i.e. the formulary issues certainly can be.  But I’m fairly certain that most electronic medical records don’t have a question or check-box for “microwave available to patient,” but these types of capabilities and non-medical types of factors are important for patients health and quality of life, and thus need to be considered by physicians’ offices as they provide comprehensive care (and not just medical services) to patients.  These are the types of issues that the “medical home” model tries to encompass by expanding the physician’s responsibility for their individual patients and emphasizing patient education through broader teams of healthcare professionals.