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Doctors Communications to Patient’s Family

By Michael D. Miller MD
February 10th, 2010

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.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications | 2 Comments »

Thanksgiving Conversations About Health - Engage With Grace Blog Rally

By Michael D. Miller MD
November 24th, 2009

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.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Miscellaneous | 3 Comments »

Encouraging Communications About Patients’ Goals

By Michael D. Miller MD
September 18th, 2009

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.

Posted in Clinician-Patient Relationships, Comparative Effectiveness, Delivery of Healthcare, Economics & Financing, Information & Communications, Quality of Care & Safety | No Comments »

Communicating with Clinicians to Improve Quality

By Michael D. Miller MD
May 8th, 2009

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.”

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications, Quality of Care & Safety | 1 Comment »

Medical Case Management - Making It Work

By Michael D. Miller MD
March 9th, 2009

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.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform | 1 Comment »

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

By Michael D. Miller MD
February 26th, 2009

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.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Information & Communications | 1 Comment »

Controlling Health Care Costs and Improving Quality with Effective Care Coordination

By Michael D. Miller MD
February 16th, 2009

A study published by in the New England Journal of Medicine last week examining the effects of 15 different Medicare care coordination demonstrations received wide coverage by the general media.  Unfortunately, much of this focused on the study’s overall finding that these programs didn’t reduce hospitalizations or Medicare spending.  For example, the AP story’s headline, “Study finds bid to cut Medicare costs failed,” was used by many papers such as the Washington Times.

However, the actual study had much more complex, important, and useful findings, and the paper’s authors from Mathematica, (which Medicare contracted to do the analysis from this project), deserve a lot of credit for extracting meaningful information from this project.

Complexity of Medicare Care Coordination Demonstration Projects
The study was very complex and presented many analytical challenges, including:

  1. The “study” involved 15 different and diverse “care coordination” programs: 5 disease management companies, 3 community hospitals, 3 academic medical centers, 1 integrated delivery system, 1 hospice, 1 long-term care facility, and 1 retirement community
  2. Despite being called “care coordination” programs, the major intervention was nurses communicating with patients outside of the patients’ direct clinical care team
  3. Most of the programs’ care coordinators didn’t have significant interactions with the physicians treating the individual patients – although reports were provided to the physicians
  4. The primary outcomes the study looked at were hospitalizations and total Medicare costs

Given that physicians direct most clinical decisions and thus influencing overall healthcare spending, it is not surprising that third party programs were ineffective in changing clinical or cost outcomes.  With the patient’s physicians not being directly engaged in the development and implementation of these programs, nor vested – either financially or cognitively – in the success of these care coordination programs, this outcome is not surprising. This is like expecting travel agents to improve the safety and efficiency of air travel, i.e. while they can provide information to individuals they are not engaged in the operations of the airplane or airports. [OK – that’s an overly simplistic example, but I think it helps make the point.]

Positive “Findings” From the Study:
Despite the disparate structure of the programs in this study, the authors found that the more successful programs:

  1. Had greater in-person contacts with the patients – nearly 1 per month
  2. Focused their efforts on individuals with higher Medicare costs
  3. Had greater success educating patients on how to properly take their medicines
  4. “Worked closely with local hospitals, which provided the programs with timely information on patient hospitalizations and enhanced potential to manage transitions and reduce short-term readmissions”
  5. “Had frequent opportunities to interact informally with physicians”

Implications for Medical Homes
These findings reinforce the importance of focusing on the role of physicians in controlling and managing clinical care decisions – which overall account for up to 80% of all healthcare spending.  This observation is consistent with the conclusions the authors of the Care Coordination study reach in their NEJM article about their findings being able to help support the implementation and success of medical homes: “The successful interventions also may offer more detailed lessons for medical homes about how best to educate and monitor patients, the types of patients for whom they are likely to be most effective, and how to help patients overcome barriers to better self-care.”

This is a very timely and important conclusion since Medicare is getting ready to launch a Medical Home Demonstration Project in 8 states – and possibly more through legislation enacted last summer. Medicare’s Medical Home Demonstration has a greater likelihood of improving quality and lowering costs than the Care Coordination project because the Medical Home Demonstrations will directly put the responsibility for care coordination and improving patient self-management on the patients’ individual physicians – as opposed to providing an outside service for patients. In addition, similar to the two somewhat successful Care Coordination projects, the Medical Home Demonstrations will focus on Medicare patients with chronic conditions.

Implications for Overall Health Reform Efforts
The Care Coordination study’s observation that the successful programs differed from the unsuccessful ones in how they improved patients’ compliance with medications also has implications for broader health reform initiatives. It makes sense that patients with chronic conditions who aren’t receiving adequate medicinal treatments would have increased costs and hospitalizations, and thus improving compliance would reduce both. This finding, along with studies about the costs associated with medication errors, point to the value of focusing on medication compliance and proper usage in initiatives for reforming healthcare delivery.

For example, improving medication compliance might be improved by creating better written instructions for patients. An analogy might be to the checklists that help surgical teams and physicians placing central IV lines reduce errors and infections. Individualized patient “checklists” created in a standard format could help patients with chronic conditions take their medicines correctly and thus improve quality and lower costs.  And of course, these “checklists’ should also include ALL the patient’s medicines, reminders about avoiding certain OTC medicines and herbal supplements that might interfere with their prescribed medicines, and to urge them to promptly inform their physicians if they develop certain signs or symptoms related to their medical conditions.

All of this really goes back to the benefits of improving patient-clinician communications, and strengthening their joint engagement with the broader care team that includes pharmacists, nurses, specialized clinical educators, and family members as appropriate.

Strengthening Care Teams Through Better Communications
Such checklists and more standardization of care protocols – for use by clinicians as well as patients – should help foster this communications and team-base management.  However, if they are viewed by anyone in the team as cookbook medicine, or impersonal standardization – rather than guidance to protect against overlooking important actions and opportunities – then these protocols will not produce positive clinical and economic outcomes.  To encourage positive attitudes and actions about such quality improving changes, clinicians and patient advocacy leaders of all types – and at all levels – will need to be educated about the value of such shifts in clinical operations, and for them to be promoted as champions of these new paradigms for clinical care. (Group visits for patients with conditions like diabetes or congestive heart failure are an example of care delivery innovations that can increase quality and lower costs through greater efficiency and engagement of patients and their care team.)

Changing Reimbursement to Support Care Delivery Reforms
Making these changes to the clinical care delivery so that they are attractive to clinicians – both in private practice and in larger care delivery systems – will likely require altering reimbursement systems to change the financial incentives.  The Medicare Medical Home Demonstration project seeks to do this by directly paying physicians for their medical home management activities.

While this Demonstration is being implemented, a more widespread and timely change in Medicare’s physician payment system may happen this year because of the unsustainability of Medicare’s “Sustainable Growth Rate” formula.  Under the current SGR formula, Medicare payments for physician services are expected to be reduced by ~22% starting in January 2010. Deliberations to avoid this “broadsword” financial cliff may be a leverage point for making such changes – although it is unlikely that a dramatic, wholesale change will occur immediately.  It is more likely that significant changes will be phased in over several years and across geographic regions.  A gradual implementation makes sense since it provides opportunities for clinicians and Medicare enrollees to become familiar with the new payment and clinical delivery structures, it enables champions for better care delivery methods to be created, and it allows those who are more cautious to observe the changes while they are implemented for and by others.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Quality of Care & Safety | 2 Comments »

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

By Michael D. Miller MD
February 9th, 2009

One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition.  CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.

Focus on Chronic Diseases - That’s Where the Money Is
This combination makes perfect sense since the majority of healthcare costs are used by the least well patients:  In 2003, 80% of health spending went for 20% of people in the US, and the Agency for Healthcare Research and Quality estimates that 70% of healthcare spending is for treating chronic diseases.

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[Source: Kaiser Family Foundation]

Emphasizing chronic disease management for Medical Homes reflects how most healthcare innovations, (including technologies, payment schemes, and care delivery changes), are first used in the most organized and intensive care settings -  such as hospitals - and then migrate out into primary care and preventive settings, including home use and patient self-management.  Thus Medical Homes’ focus on care coordination for chronic conditions parallels the decades old movement and growth in team-based care in hospitals.

Medical Homes and Wellness Care
Beyond improving chronic disease management, Medical Home capabilities should also help promote better wellness for all patients, i.e. the other 80% of people.  Patients wellness from better exercise, diet and other actions could be improved through Medical Homes providing more targeted counseling and self-management training.  Similarly, Medical Homes use of patient registries and reminder systems should increase compliance with vaccinations, prenatal vitamins, and reminders to follow-up on patient specific wellness interventions.

Long-Term Vision for Medical Homes
The long-term vision for Medical homes should include how they can improve clinical care for all people in a community - not just those with chronic or costly illnesses. As I work with payers, clinicians, and others about the desired characteristics of Medical Homes, this vision should help shape how payments for providing Medical Home services are structured and evolve, (e.g. PMPM for specific sets of Medical Home capabilities), and how additional compensation - such as bonuses - are constructed and modified to reward Medical Homes for achieving clinical and cost outcomes. Such a vision should also be part of our national long-term strategy for making healthcare delivery more efficient and coordinated, and transforming our delivery system’s culture to embrace the rapid adoption of change to provide greater clinical and societal value.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Quality of Care & Safety | 1 Comment »

Quality of Care in Medical Practices - Size Does Matter

By Michael D. Miller MD
January 19th, 2009

The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes.  These structural capabilities represent process measures that assess the quality of care in medical practices.  However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care. The most significant difference in capabilities was seen in practices with 5 or more physicians, and these included:

  • Practice meets to discuss quality more frequently than every quarter
  • Practice regularly open to provide care on weekends
  • Use of Electronic health records that provide medication list, problem list, and electronic reminders

In addition, practices with 9 or more physicians were more likely to have specialty trained staff to assist with patient self-management, and there was an overall trend for larger practices to have reminder systems for preventive care:

Quality Improving Capabilities Increase with Practice SizeAsking Questions to Improve Quality
The questions used by the researchers in this study are clearly useful for assessing the quality relate capabilities of primary care practices, but additional research certainly it warranted to determine how well these process measures translate into actual improvements in clinical and economic outcomes. In addition, as such lists are developed and validated further, they could also be used by individuals looking for their own primary care physicians, and by patient advocacy organizations seeking to both promote quality improvement and to “grade” primary care providers.

The specific questions used in the study’s survey was:

Quality Capabilities for Primary Care Practices

One of the challenges for individuals or groups to effectively use any list of this type is that it needs to be customized because they will have different priorities and concerns. For example, the availability of translation services might be important for one family or advocacy organization, but less so for others.

Conclusion
Much has been written about using checklists to improve quality and reduce errors in hospitals - and particularly in the operating room.  But perhaps checklists could be derived from this type of Medical Home capabilities survey for use by individual patients and their advocates to assess outpatient clinical sites.   While the operating room checklist concept was based upon the airplane pre-flight checklist, maybe the checklist for assessing primary care practices could be likened to the checklist that home inspectors use to help home buyers understand the strengths and problems of a house. If individual patients and their collective advocacy groups regularly used checklists of this type, it could create a significant patient driven force for transforming the structure and operations of outpatient medical care in the United States to improve quality and control costs.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Health System Reform, Information & Communications, Quality of Care & Safety | 6 Comments »

Making Physicians Better, and Making Better Physicians

By Michael D. Miller MD
December 10th, 2008

A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions.  The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

  1. Ask permission to enter the room; wait for an answer
  2. Introduce yourself; show your ID badge
  3. Shake hands
  4. Sit down. Smile if appropriate
  5. Explain your role on the health care team
  6. Ask how the patient feels about being in the hospital

Clearly these actions are all directed towards creating a stronger person-to-person connection between the physician and the patient as a step toward improved communications - which is the foundation for developing and effectively delivering a treatment plan to and for the patient.

Physicians Getting Rest
Another challenge physicians have in this process is being awake and aware enough to actually engage in those 6 steps. (Having enough energy also would effect their ability to engage patients empathetically - something I’ve written about before.)  [Also see the previous posting about napping being better than caffeine for improving verbal and physical memory and learning.]

How much sleep physicians need to act appropriately - and avoid making errors - is the subject of a recent Institute of Medicine report, (“Resident Duty Hours: Enhancing Sleep, Supervision and Safety”), that makes new recommendations for limits to the work hours for physicians in training:

  • Duty hours should not exceed 16 hours per shift; For 30 hour shifts there should be an uninterrupted five hour break for sleep
  • Residents should have variable off-duty periods between shifts based on the timing and duration of shifts to increase residents’ opportunities for sleep each day, as well as regular days off that enable residents to recover from chronic sleep deprivation.
  • Medical moonlighting, (additional paid healthcare work), should be restricted
    [A chart comparing the current and new recommendations is available here.]

While all these changes would certainly make for more aware and awake residents, the IOM also estimates that recruiting and paying professional staff to substitute for the work hours the residents would have been (over)working, would cost about $1.7 billion.

Besides figuring out how to pay for these new staff hours, one policy question for implementing these recommendations is how to find the clinicians to actually work these hours considering there is such a shortage of non-physician clinicians.

Anther policy question these recommendations raise, is why they should they only apply to physicians in training?  Why shouldn’t they also apply to physicians who’ve finished their training and are supervising, teaching, and mentoring residents and medical students - and of course are directly responsible for patients?  While it might be argued that most physicians don’t work these long hours, for some that may not be the case - particularly in hospitals without many residents.

Considering that many quality improvements for medicine have been taken from the airline industry - such as the pre-flight/pre-surgery checklist - then why shouldn’t the limits on pilot shifts and hours also be applied to fully licensed physicians?  [I suspect that this will not make me popular with some physicians, but I wonder how they will defend their right to treat patients round-the-clock without sleep?]

Conclusions
Perhaps work hours and etiquette should be other aspects of quality improvement and patient safety that are considered as part of health reform discussions at the Federal and State levels. Certainly well-rested, empathetic physicians trained to interact with their patients with etiquette should improve the quality of healthcare by reducing errors and making physician-patient communications more effective.

How to integrate all these “innovations” into physician training and practice will be a significant challenge, because teaching such skills and promoting their use is not very exciting or technological, and it will be hard for such behaviors to be tied to economic incentives - which are often the carrot or stick for quality improvement initiatives.  Hopefully, as health reform ideas move forward and become crafted into comprehensive packages and plans, they will expand beyond direct economic incentives for improving clinical processes, to include non-economic inducements to promote quality enhancing actions and attitudes for clinicians as well as patients.

Posted in Clinician-Patient Relationships, Delivery of Healthcare, Economics & Financing, Health System Reform, Public Health, Quality of Care & Safety | 5 Comments »

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