Sunday, May 18, 2014

Transitions of Care

Americans have a tendency to overcomplicate. The cartoonist, Rube Goldberg, satirized that tendency in the 1920s and 1930s with his intricate designs of complicated inventions contrived to serve simple purposes.  His legacy lives on through the Rube Goldberg Society.  Unfortunately, the Rube Goldberg devices we create in the health care system are often not quite so amusing. 

A classic example of a Rube Goldberg device 
It is helpful to think of Rube Goldberg devices when we evaluate different issues related to patients who have to go from home, to inpatient hospital stay or to outpatient “day” surgery (which can easily last more than a day) and then back to the home.  These types of “transitions” of care used to be relatively easy.  The patient would be in the hospital longer than today, with all the harms of hospital borne infections and all the benefits of prolonged recovery times.  The primary care physician would visit the patient daily and provide stability through the transitions. The transitions were handled by a single professional who saw the patient as the focus of their attention, regardless of where the patient was being treated, and who truly walked the patient through the difficulty of those transitions.  Admittedly this was inefficient and possibly less medically sound than our current use of focused hospital professionals. 

Today, we find ourselves in a world of hospitalists, surgeons, facility based procedural specialists and primary care specialists who never leave their offices.  Communication is supposed to be driven by improving electronic medical records and other technologies rather than by professionals actually talking to each other.   After all, professionals talking to one another is considered to be inherently inefficient and very hard to fit into tightly scheduled calendars.  This leads to problems in transitions which leads to high readmission rates and poor quality of care when people go through those transitions.   It leads to people feeling alone and abandoned as they traverse the various sites of care that modern medicine demands.  People leave the hospital and don’t keep follow up appointments with their doctors.  They never fill the prescriptions that they need.  Problems fester when they should be evaluated rapidly because patients and families don’t know who to call.  Complications that could be simply treated if found early are missed and turn into major problems. 

The medical profession recognizes this problem and a recent editorial in American Family Physician addressed it.  The authors of the editorial stated:

“The effectiveness of hospital-based care transition programs is unclear.  Although some programs reduced 30-day re-hospitalization rates, a systematic review found that no single intervention is reliably helpful, and successful readmission programs generally occur only in single institutions.  However, it seems that programs that focus on the whole patient rather than a specific diagnosis are more successful in reducing readmissions.
The italics are mine.  Are we losing this whole patient, and more importantly whole person focus?  I fear we are.  The authors of this editorial do not suggest going back to primary care physicians seeing their patients when they are in the hospital.  They know that those days are gone.  They are not suggesting longer hospital stays as they recognize the dangers both medically and fiscally of going back to that system.   

The editorial sees better electronic communication between the facility’s doctors and the primary care doctors as one way to solve the problem with more standardized systems to nudge primary care doctors to automatically contact their patients from 24 to 72 hours after discharge.  To their credit, the authors mention the need for more communication between the hospital based professionals and the outpatient based professionals as the transitions occur.  However they do not address the transition from the patient’s point of view, as the patient and their family travel alone through the illness journey. 

Even in the “good old days”, a critical piece of the puzzle was missing, which was a “diagnosis” of the home environment and how that may or may not be conducive to healing.  However it was much less of a factor as people left the hospital much later in their recovery than in today’s world and the family doctor tended to know more about the person’s home life as they often treated the entire family and knew their patient over time.  Today that home and social diagnosis is a critical missing piece to the puzzle of better managing transitions. 

I worry that in trying to create solutions that are systems based and are designed from the doctors’ point of view the health care system may be missing the very human issues involved in maximizing care and recovery.  Are we are trying to create Rube Goldberg devices using modern technology when something much simpler is needed?  Perhaps the issue is that we need a person, much like the primary doctor of old, to be with the patient as they take their journey through the health care system.  That person need not be a doctor.  Perhaps we need a new profession that combines certain aspects of social work, nursing and insurance consulting to help people through all those issues, either medical, social, or financial no matter where they are in the health care system and the health care continuum.  We have been building such a group of professionals at Accolade and we hope others will follow our lead in developing a profession to help a person through all of the transitions in as simple a manner as possible.  

Sunday, May 4, 2014

How Well Do Doctors Listen and Care? – Measuring Quality that Matters to the Patient

For many years, health care systems, government and insurers have attempted to measure the quality of care delivered by individual physicians.  In health systems, the main methods used to evaluate doctors rely on the mining of the medical record and patient surveys.  The article by Weiner and Schwartz published in the April issue of the Journal of General Internal Medicine, points out the challenges of these current methods and suggest another option of directly observing the encounter between a doctor and a patient.  The current methods, the authors rightly point out, are flawed.  In the article they state:

“Neither captures an array of performance characteristics including clinical attention to symptoms and signs while taking a history or conducting a physical examination, accurate recording in the medical record of information obtained during the encounter, evidence based communication strategies for preventive care counseling, and effective communication behavior.”

They do not comment on two other modalities used to measure physician quality and that is mining medical claims data and standardized patient forms used mainly to document activities for insurers and regulators, such as informed consent forms before surgeries and forms meant to inform about privacy and confidentiality laws.  These two are even more flawed than the use of medical records and surveys and yet many millions of dollars are spent each year just to manage the use of these claims databases and the flow of the attestation forms.  These two, admittedly inferior techniques are the main ones used by payers and regulators who turn to medical records and survey tools only rarely as the costs of these types of reviews tend to be high
Therefore we have four data sets, all of them admittedly flawed which we currently use to measure physician quality.  The direct observation, in this article accomplished by unannounced standardized patients and in other articles by this team by the use of audio recordings of patient visits, is a tremendous step forward as this fifth type of dataset can potentially be the most powerful of all.  When the work of Wiener and Schwartz and others who are pursuing this more direct evaluation methodology is reviewed in total, it points to a few truths so obvious that they rise to the point of being profound.  The following truths are my interpretation alone and are not part of the work cited.

  • Just because patients sign a form, that does not mean they understand what they signed and that the communication of the contents of the form actually occurred.  More often than not, for example,   HIPAA forms are given to patients as they first register at a practice or a facility by a clerk who does not explain the form of even understand it him or herself. 
  • A claims data base, which is a financial record used for billing and reimbursement purposes, is often not an accurate measure of what really occurred during a patient visit.  While useful for macro purposes, it is much less useful for assessment of individual practitioners.
  • Big data clarifies big trends and hides small differences.  It is often the small differences that matter to the individual patient. 
  • Patients don’t know what they don’t know so surveys devolve into popularity tools rather than true assessment tools of good clinical skills, listening and assessment quality, and abilities to truly understand the context of a patient’s life that is critical to their ability to carry out recommendations, follow advice, and change destructive behaviors. 
  • To assess listening, you have to listen.  Weiner and Schwartz, in their numerous studies over a decade demonstrate this repeatedly.

Only focusing on evidence based algorithms and value as measured by cost benefit analysis devalues the professional art, which may arguably be the most important part of medical practice.  Ultimately, the quality of a physician, and of any health professional, is dependent upon their ability to see and understand their patient as a unique individual, and then apply the appropriate best practices in the context of that person’s life and values.  The truly gifted practitioners do this as an art form, applying science at a very high level while always testing to ensure that they are bringing value to the patient, in the physical, social, emotional and even financial realms.   We have to measure that professional ability and develop the right methods to do that effectively and consistently.