Making Sense of the Complexity and Keeping Perspective

After several decades studying our healthcare system and seeking solutions to the crisis, we've had to address multiple complex issues concerning such things as evidence-based medicine, clinical outcomes, performance measurement, quality improvement strategies, cost control methods, transparency of cost and effectiveness, health information technology, and the use of incentives. I found it is easy to get lost and confused unless you have a big picture view to help keep the details in perspective.

One way to keep such a perspective is to see the solution as a series of changes in healthcare policies and practices focused on enabling all patients to receive the most cost-effectiveness care – be it well-care (i.e., prevention), catastrophic care, and compassionate end-of-life care. This means:

• Patients and providers must know the best (most cost-effective) treatments/interventions for each particular health problem/risk
• Providers must be able and motivated to deliver that care
• Patients must able to select the best providers to treat them and be motivated to comply with their plans of care.

Accomplishing this requires addressing the following issues (among others):
1. We have to replace ignorance (see the Knowledge Gap) with a concerted collaborative effort to gain the knowledge needed to make better decisions. Two tactics to achieve this are;

• The development, dissemination, and implementation of evolving evidence-based practice guidelines, which includes dealing with the difficulty of using outcomes data to evaluate performance. Implementing this tactic requires addressing several problems with current practice guidelines and quality improvement (QI) programs.

• The use of evolving health information technology (HIT) tools, including advanced knowledge tools for supporting diagnostic and treatment prescription decisions and driving an evidence-based decision support process. There are several concerns about HIT and solutions.

2. Current day policies and practices, which impede providers from spending the time and having the resources to give patients the best possible care, should be changed (See Healthcare Fidelity )

3. Treatment decisions should be tailored to the specific needs of the individual patient taking into account the person’s age, gender, race, genetics, environment, concomitant treatments, quality of life preferences, and other factors that may be relevant to a high-quality plan of care (see Personalized Care ).

4. Increasing provider motivation to change is another issue needing resolution. This is related to the Pay for Performance (P4P) issue.

5. Creating a sane payment system would certainly help, including addressing the issue of transparency of care cost and effectiveness.

6. Consumers should be better informed so they can distinguish among levels of quality by knowing the relative cost and degree of defect (underuse, overuse, and misuse) of healthcare resources.

7. Consumer education and wellness programs are also important so people can help prevent their own health problems and managed chronic conditions effectively.

Not Enough Patient-Centered Care

The Commonwealth Fund recently reported on a study that only 22% of physicians practice “Patient-Centered” care. Also called "Consumer-Centered" care, it is an approach to that includes a list of practices designed to improve care quality and patient experiences.

Why is this? The authors conclude a lack of training and knowledge about how to adopt patient centered care into their practices, as well as a concern about costs.

"With the right knowledge, tools, and practice environment, and in partnership with their patients, physicians should be well positioned to provide the services and care that their patients want and have the right to expect."

Another way of saying this is that we need a "high-fidelity" healthcare system. Fidelity exists only when healthcare systems enable:

• Patients to make their care needs known to providers through adequate access and communication
• Clinicians to have the time, knowledge, skill, and attention necessary to recognize a patient needs and intervention
• Interventions to be delivered properly, safely, and in a coordinated manner.

A high-fidelity healthcare system:

• Makes it possible for coordinated teams of clinicians to render care across the entire healthcare continuum
• Assures that providers have adequate resources, and competent information and decision support tools
• Is fully committed to consumer-centered care.

Shouldn't we be focused on changing policies and practices that block high-fidelity and prevent patient-centered care from being the standard?

Steve

Proposal: Linking Communities of Healthcare Blogs with Wikis

Collaborating communities of healthcare professionals and consumers are essential to solving the healthcare crisis. Through news feeds, conversation and knowledge-sharing, these communities help increase people's understanding, spark innovation, provide decision-support, enable better problem-solving, and mobilize grass-roots efforts.

The most practical way to do this is through "virtual communities" using communication vehicles such as blogs, wikis, forums, list serves, and real-time workspaces. Each of these technologies has certain unique capabilities, as well as overlapping functions.

Following is a proposal that combines these different vehicles in an optimal way enabling virtual communities to generate, evaluate, evolve, and implement strategies and tactics for solving the healthcare crisis from the "bottom-up" through grass-roots action.

Unlike a blog, a wiki is an excellent vehicle for organizing content, like an encyclopedia, using links to pages via a table of contents or taxonomy, which gives a comprehensive “whole-picture” view. It enables the reader to navigate quickly and easily from topic to topic, category to category, and can handle many different links to reference materials and other external information sources. And it allows collaborative editing by authorized contributors who can modify and add content right on the wiki pages. They also enable comments, as does a blog.

Blogs, on the other hand, do not organize content into a comprehensive view. Instead, posts appear chronologically, not organized by topic. This is a good way to deliver a variety of different issues for review and discussion, like a news feed. The reader scans through the issues of the day, reads the ones they want, and post comments as desired. When the comments stimulate community dialogue, blogs help surface new ideas, challenge people’s assumptions, and lead to greater learning.

So, wikis are like encyclopedic organizers and blogs are like newsfeeds, both of which enable conversations. How can they be used together for maximum benefit?

Well, when it comes to focusing virtual communities on something as complex as finding solutions to the healthcare crisis, I suggest using our Wellness Wiki as a vehicle for organizing and growing content, and using a community of blogs to “feed” the wiki. What I mean is that the blog posts would:

• Present timely information (news, studies, insights, opinions, experiences, questions, etc.) on different topics of interest (some of which might even be based on content from the wiki itself).
• Engage people in short-term dialogue about that information.
• Have links to them from the appropriate wiki pages, so people reading a topic on the wiki can easily navigate to the associated blog posts. If a post does not have a corresponding page on the wiki, because it introduces a topic absent from the wiki, then the wiki should be expanded to include that topic.
• Contain links to specific pages in the wiki as is appropriate.

In some ways, this is like a blogs aggregator, except that each blog post is organized in the wiki by topic/category, not by the time period in which the posts happen to appear.

If certain topics in the wiki require deep continuous dialogue, lengthy posts, branches into sub-topics, voting capabilities, file exchange, etc., then a virtual forum can be set up for that purpose.

If any bloggers are interested, please contact me.

Steve