Monday, October 29, 2007

Patient-Centered Life-Cycle Value Chain: the Well Care link

In my previous post, I discussed the second link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is sick-care. In this post, I discuss the third link, which involves well-care, as well as the integration of emergency-care, sick-care and well-care.

Well-Care (Prevention & Self-Management)

The third link in the PCLC Value Chain involves well-care, which includes prevention & self-management. Three well-care delivery models are the:
  • Preventative Maintenance model, which focuses on (a) delivery of primary prevention -- such as physical activity, nutrition, stress relief, vaccinations, etc. -- that help people avoid health problems, as well as promoting peek performance, and (b) secondary prevention for at-risk persons to prevent recurrences of health problems, such as avoiding recurrent coronary artery disease events in a person with a history the illness.
  • Recovery/Rehabilitation model, which focuses on adherence (compliance) to doctors’ orders to foster recovery, rehabilitation, and complication avoidance for patients having chronic or catastrophic health problems.
  • Compassionate Home Care model, which focuses on making people near end of life as comfortable as possible in a supportive environment where they have dignity and family support.
Well-care is delivered by wellness coaches/practitioners, such as specially trained physician assistants, nurse practitioners, home health aids, personal trainers, and others:
  • Recovery/Rehabilitation and Preventative Maintenance well-care may be delivered face-to-face, over the internet, and via phone sessions. They include processes for: (a) ongoing risk and health status assessments; (b) ongoing generation of personal health plans identifying any risk factors people may have, as well as primary and secondary prevention plans of action (i.e., health directives); (c) health education presenting concrete, understandable action steps and psychological counseling for dealing with physical problems and psychological stressors; (d) compliance motivation involving motivating and reminding people to do the things that will help them improve their own health; (e) accessing health coaches for health information and advice; (f) outcome studies used in continuous quality improvement feedback loops; (g) care coordination for patients with catastrophic health problems, so multidisciplinary teams can work together effectively; (h) promotion of environmental and workplace safety; and (i) encouraging lifestyle and attitudinal changes for peek performance.
  • Delivering Compassionate Home Care well-care includes processes for helping individual obtain home care nursing and homemaking assistance; arranging for transportation to and from doctor appointments; and addressing the psychological, social and spiritual well-being of patients and families.

Integrating Emergency-Care, Sick-Care & Well-Care in the PCLC Value Chain

Instead of viewing emergency-care, sick-care and well-care as separate and distinct, the PCLC Value Chain solution integrating all three. This process involves a new kind of coordination and collaboration between:
  • First responders focused on safe passage to and from disaster sites, victim rescue and triage, and trauma center response
  • Medical and related sick-care practitioners focused on the diagnosis and treatment of health problems
  • Well-care practitioners focused on prevention, recovery, and self-maintenance.
This integrated care strategy promises to bring the greatest value to patient/consumers over their life times by helping assure adequate resources are available and the right care is delivered cost-effectively in all possible situations. It provides a sensible way to keep people healthier longer, recover from illness and dysfunction more quickly, avoid complications of chronic disease, and enable first responders to rescue victims effectively in emergencies. This shifts our current healthcare system from being overly focused on episodic acute care to embrace prevention and chronic condition management, as well responding in emerging environments.

In subsequent posts [starting here], I discuss what’s needed to implement this integrated care strategy successfully, including:
  • Specific clinical and financial processes of our current healthcare system that must be transformed
  • Specific infrastructural needs, in terms of health information technology use.

Monday, October 22, 2007

Patient-Centered Life-Cycle Value Chain: the Sick Care link

In my previous post, I discussed the first link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is emergency care through emergency management. In this post, I discuss the second link, which involves sick-care, also known as the “clinical encounter” between a patient and one or more healthcare providers.

Sick-care consists of the following six categories of physical and psychological problems (including diseases, illnesses, dysfunctions, and traumas):

  1. Acute health problems characterized by sudden onset and short duration, which progresses rapidly and require urgent care. An acute myocardial infarction (heart attack) and serious accident victim are examples.
  2. Subacute health problem distinguished by abrupt onset, but it has longer duration or changes less rapidly than acute problems. Examples include post-operative care, complex wound management, and rehabilitation for stroke.
  3. Chronic health problem of indefinite duration, which may persists with virtually no change over time, or which may lead to complications. Diabetes, depression, congestive heart failure, hepatitis and asthma are examples. Note that once stabilized, enabling patients to adhere to plans of care for avoid complications and premature death is part of well-care.
  4. Physiological health problems consist of illnesses and dysfunctions in any part of the body.
  5. Psychological health problems consist of emotional, mental, or behavioral disturbances and disorders.
  6. Mind-Body (Biopsychosocial) health problems are related to the interaction between physiological and psychological factors.
Sick-care has five sick-care delivery models for delivering tests and procedures (treatments):

  1. Inpatient Care model focuses on treating patients in hospitals, nursing homes, and other inpatient facilities.
  2. Outpatient Care model focuses on treating patients in the offices of primary care physicians and specialists, clinics, and other outpatient facilities.
  3. Medical/Bodily Care model focuses on delivery of (a) emergency medical care (e.g., accident victims, infections, poisoning, etc.) and (b) non-emergency medical and non-medical bodily care (e.g., elective surgery, chiropractic, dental, vision, etc.).
  4. Psychological Care model focuses on delivery of medical/psychiatric and non-medical/psychological care for mental, emotional, cognitive, and behavioral problems.
  5. Biopsychosocial/Integrative Care model focuses on delivery of integrative (mind-body) care for problems having physiological and psychological causes or consequences.

Sick-care delivery processes focus on diagnosing and treating health problems in inpatient and outpatient sick-care settings:

  1. Inpatient care processes for physical and psychological health problems including (a) emergency room/trauma center care; (b) obstetrics; (c) tests and examinations; (d) elective surgery; and (e) psychiatric care for severely disturbed patients.
  2. Outpatient care processes physical and psychological health problems including (a) tests and treatments for physical and psychological problems during primary care during office visits to primary care physicians and specialists, as well as to ambulatory clinics and other such facilities, and (b) coordinating care for patients requiring multidisciplinary teams can work together effectively.

A core problem with sick-care today is that we rarely know what constitutes cost-effective (high-value) sick-care that is tailored to a patient's particular needs and characteristics. That is, we lack patient-specific evidence-based guidelines about how to treat each patient so they get well rapidly and with least risk and complications. This is because our country hasn't focused on supporting the kinds of research and information systems necessary for generating and using the knowledge (best practices) providers and patients need for improving treatment outcomes/results and controlling costs.

On top of that, high-value sick-care is less profitable than wasteful, inefficient, redundant, excessively costly and error-prone care. This is because our crazy payment system rewards high volume and costly procedures through higher profits, while it discourages the efficient delivery of cost-effective care through lower profits.

In the PCLC Value Chain, therefore, sick-care focuses on:

  • Using and evolving evidence-based practice guidelines defining how to deliver cost-effective care
  • Assessing and improving clinical outcomes continuously
  • Empowering healthcare consumers to make knowledgeable decisions about their own care by being active participants in shared decision-making
  • Treating the “whole person,” both physically and psychologically
  • Tailoring care to each person’s specific needs and preferences
  • Coordinating care and facilitating cooperative communications across all providers treating a patient for better continuity of care
  • Fostering collaboration between practitioners and researchers
  • Maximizing safety and efficiency
  • Utilizing advanced information systems for supporting diagnostic and treatment decisions
  • Assuring greater financial gains to providers dedicated to delivering high-value care.
In my next post, I examine the third link in the PCLC Value Chain: Well-Care.

Tuesday, October 16, 2007

Patient-Centered Life-Cycle Value Chain: the Emergency Care link

In my last post, A Path to Profound Healthcare Transformation, I discussed how our low-value healthcare system is built upon our country’s pathologically mutated form of capitalism. I then described a new direction for transforming the current broken system into a high-value patient-centered system that delivers top quality care and does it efficiently and at a good price (i.e., cost-effectively) over a person’s entire lifetime.

This past week I came across two more articles that support my call for value to the patient.

The first one, Healthcare 2015: Win-win or lose-lose?, reported that:
Healthcare is in crisis…[and] will become unsustainable by 2015…

Value is in the eye of the purchaser, but today value in healthcare is difficult to see. Data regarding the healthcare price is tightly held and difficult, if not impossible, to access or comprehend; quality data is scarcer still and mostly anecdotal or incomprehensible. To complicate matters, the purchasers and benefactors of healthcare – consumers, payers, and society – all have different opinions as to what constitutes good value. Balancing and resolving these conflicting perspectives is one of the major challenges in the successful transformation of healthcare systems.

Today, consumers often have little direct responsibility for bearing the costs of healthcare and their ability to predict healthcare quality is equivalent to a roll of the dice. Payers – public or private health plans, employers, and governments – shoulder the burden of healthcare costs, but often incentivize poor quality care in pursuit of reduced episodic costs. Societies tend to pay little attention to healthcare costs or quality until service levels for healthcare or other societal ‘rights’ are threatened.
I contend that the only way to deal with our healthcare crisis is by defining value from the consumer/patient point of view, as well as enabling us all to obtain cost-effective care and be rewarded for doing so. In addition, providers and insurers who deliver the greatest value to the patient/consumer should enjoy competitive advantage and reap greater profits.

The second article, titled Survival Plan--which is written by a fine author, Maggie Mahar--reports how the Medicare Payment Advisory Commission (MedPac) warned that:
…unless Congress makes some hard decisions about how to contain health-care spending, Medicare won't be able to sustain its current program -- let alone expand coverage to the entire nation…if Medicare continues spending at the current rate, it will hit a wall in twelve short years: At that point, the trust will be able to cover only 79 percent of Medicare's costs. …Billings from physicians [have been] spiraling, largely because the volume and intensity of the services they provided were rising. This was in part because …Medicare pays physicians fee-for-service. The more they do, the more they are paid. In other words, the financial incentives of the fee-for-service system reward quantity, not quality.

Many physicians argue that in recent years they have been forced to "do more" just to maintain their income stream. While the cost of real estate, supplies, and malpractice insurance climbs, their fees have not kept up. They must make up the difference, they say, "on volume." Few consciously over-treat patients, but many see more patients more often-- which means that those patients receive more tests and treatments, and Medicare receives more bills…from 2000 to 2006, Medicare spending for physicians' services rose by more than 9 percent annually.

… In some parts of the country, Medicare spends twice as much per beneficiary as in other parts… In high-spending regions, patients undergo more tests, spend more days in the hospital, and are far more likely to see ten or more specialist during the final six months of life -- for reasons that have little to do with either medical necessity or patients' druthers… And here is the shocker: Patients who receive the most aggressive care fare no better than those who receive more conservative care. In fact, often, outcomes are worse.

…[One suggested solution by MedPac to Congress was to] abandon "fee-for-service," and pay physicians for quality and efficiency. Those who achieve the best outcomes -- while using fewer resources -- would earn more. …Long-term, this could lay the foundation for high-quality, affordable care.
So, the need to bring patient-centered value to our healthcare system is critical! Our Patient-Centered Life-Cycle (PCLC) Value Chain is a sensible path for our country to follow.

I previously said that integrating emergency care, sick-care and well-care is the cornerstone of the PCLC Value Chain. This is because high-value to the patient means receiving the care you need when you need it, including:
  • Emergency care through emergency management if you are in an accident or if you are by a disaster site
  • Sick-care if you are ill and need to see a doctor
  • Well-care if you want to avoid becoming ill through prevention, and to keep chronic conditions (like diabetes or heart disease) from causing complications or premature death.
In this post, I will discuss emergency care from a PCLC Value Chain perspective. My subsequent posts will focus on sick-care, well-care and the integration of all three. After that, I will focus on describing the clinical and financial processes the need to be reformed, followed by the infrastructural needs surrounding health information technology use.

Emergency Care Through Emergency Management

The first link in the PCLC Value Chain involves emergency management. In an emergency, especially in a widespread disaster, saving lives and property depends on the timely exchange of information between command & control units, 1st responders (fire fighters, police, EMTs, trauma center staff, etc.). Our current system has failed in many areas, as witnessed by the Katrina and 9/11 disasters. We are vulnerable; the threat is real. Systemic changes needed to handle disasters include establishing Emergency Information Exchange networks that enable the following:

  • Identification of the safest routes to and from a disaster site. We have to assist 1st responders in finding the safest routes to the site of a disaster, as well as the best routes for transporting rescued victims from the triage point to a trauma center. This requires obtaining environmental data (including roads and air) from the DOT, NOAA, FEMA, CDC, etc. to help identify the best routes for emergency vehicles to take to and from the disaster site.
  • 1st responder and victim location, tracking and least-risk extraction: We have to improve the assistance given to 1st responders as they attempt to find and extract victims from the disaster area, including rescues from destroyed buildings. This requirement involves helping them locate victims, identify safe routes to and from the victims, as well as tracking the location of the 1st responders themselves in case there is a “man down” situation.
  • Victim triage, transport and tracking: We have to do a better job assisting EMTs (emergency medical teams) in evaluating victims’ conditions and initiating emergency care at the triage point. In addition, they must have help determining appropriate transport locations, as well as tracking victims as they travel from triage to trauma center.
  • Durable and reliable communications between 1st responders, trauma centers, and all other emergency personnel: We have to enable real time connectivity and clear communications between emergency personnel in real time using systems that work well even when broadband is down and the Internet is unstable. Sometimes only “spread spectrum” radio communication will do, but even that can be blocked by the structures of a high-rise building. In addition, conversations between multiple parties using the same communication frequency (i.e., “chatter”) make it impossible to understand what’s being said. So, we need a system that connects individuals in close proximity to one another and in a way that blocks out unwanted chatter.
  • Integration of disparate data in real time and the ability to share the data in user-specific composite reports: The information that emergency personnel need must be obtained, in real time, from disparate data located in many different repositories. These data must then be integrated to generate composite reports, which are tailored to each person’s particular needs.
  • Monitoring and managing resource use with instruction, reminders and alerts: We need a better way to monitor and manage trauma center (and other hospital) resources through delivery of instructions, reminders and alerts. This includes using efficient and effective means to:
    • Establish plans of care (PoC) using evidenced-based practice guidelines and track their implementation
    • Alert authorized staff when PoC orders are due to be implemented, as well as when the failure to implement the orders in a timely manner are likely to cause problems in the care of other patients
    • Evaluate required against available resources to determine if there are adequate staff, beds, medications, equipment, supplies, etc. to care for patients’ entire length of stay, and notify authorized personnel when resource shortages currently exist or are projected
    • Enable resources to be increased or PoCs to be adjusted in order to account for resource shortages
    • Generate reports showing healthcare delivery performance and giving insight into ways to improve the performance.
  • Transition from paper records to electronic health records: Paper-based health records, that haven’t already been destroyed, are of little use in a disaster. This is why we must speed the transition to electronic health records.
In my next post, I examine the second link in the PCLC Value Chain: Sick-care.

Monday, October 01, 2007

Think Small and Don't Rock the Boat

This post refers to two related articles. One is “RHIO experts talk about problems, future of movement” and the other, which is a response to the first, is “Key to RHIO success: Stop thinking big.” Following are my thoughts on all this. Let’s begin with some definitions. RHIOs (Regional Health Information Organizations) are “consumer-centric” governing entities focused on improving care value (i.e., care quality, safety and affordability) by enabling healthcare providers (hospitals and clinicians) to share patient information securely. This information sharing is done through Health Information Exchanges (HIEs), which tie together providers—via centrally controlled or decentralized networks—using different computer technologies. And, although it is rarely discussed, a RHIO may also include Emergency Information Exchange (EIE) networks, which help first responders rescue, triage and transport victims to trauma centers when disaster strikes. In the first article, several people involved in disbanded RHIOs were interviewed about the problems they faced and the insights they could offer. I was struck by some of the comments made. One gentleman said:
"One problem with RHIOs…is that they provide the bulk of their benefits to patients and health plans, people and entities that, according to our current healthcare payment structure, either don't pay at all for RHIO startup and operational costs, or pay a disproportionately small share … It does not make sense for a RHIO to have a consumer-centric model because, even though it’s a noble idea to put the patient first, … the technology [they need] will be funded by ... the federal government and the providers themselves … This model fails for two reasons. First, each entity is already managing an incredible list of internal priorities. Second, each entity currently operates at a different level of technological readiness. Through collaboration, without the restraints of a formal structure, [a] RHIO initiative is free to build partnerships through pilot projects among ready and interested entities...
So, according to the interviewee, many healthcare providers do not consider improving patient care a priority because it requires the use of technology to exchange patient information, which eats into their profits. This, in a nutshell, is why providers are out to destroy consumer-centric RHIOs. While I don’t know how many providers agree with his conclusion, I know one thing for sure: It’s disgusting that our healthcare system puts patients and their providers in such a rotten position! Making providers choose between profit and quality is reprehensible!!! Shouldn’t our healthcare system encourage and reward providers for improving the quality and efficiency of care their patients receive?!? With this question in mind, let’s turn to the second article, which is a response to the one I just discussed. In it, a person from the well-respected Markle Foundation is interviewed about his thoughts on RHIOs. His main point is that RHIOs ought not focus on putting in the technical infrastructure required for exchanging data
“...[until the] stakeholders can begin using it [otherwise it will lead to] debates over funding, business models, data ownership and any number of other issues that have prevented or significantly slowed the development of RHIOS.”
Instead, he suggests that RHIOs
“...start small and create a sort of ‘value chain’ between payers [insurers] and providers that builds on incremental success. Eventually, RHIOs, as originally envisioned, will logically emerge.”
He goes on to say that the way to start is by having payers share their patient data with providers for free. Then, once the providers using the data
“…grow to appreciate and depend on it … chances are providers will be more eager to share their data...[and eventually]…all entities on a patient's care team [will be willing to] share richer data… including real-time best practice and clinical decision support [information]. In effect, this would serve as the foundation for the larger, system-wide health information exchange necessary for reforming healthcare.”
OK, let’s see if I have this straight. Payers collect claims (administrative) data, which are used primarily for payment purposes; they don’t offer much useful clinical information for improving care quality and efficiently. Sure, it’s important for a practitioner to have certain claims data, such as what diagnoses, procedures, medications, and immunizations a patient has received in the past, if they don’t already know it. But, unlike claims data, rich clinical information—which no payer collects—is much more useful to providers. Such information includes: • Changes in a patient’s lab test results over time in response to different treatments and conditions • Symptoms a patient has reported and is reporting • History of vital signs • Treatment guidelines best suited for the patient • Plans of care being implemented by different providers • Outcomes of prior care • Imaging studies (e.g., x-rays). • Functional status • Risk factors • Drug interaction warnings • Etc. THIS is the kind of information that helps improve care quality and avoids costly errors by supporting clinical decision, but it is not what payers are able to share with practitioners (even if they wanted to). The article concludes with this:
“So, ironically, the key to RHIO success is to stop thinking big. Instead, we should focus on smaller initiatives that generate some legitimate return on investment. Once everyone involved begins to see the results, interest and enthusiasm will build until we have ourselves a legitimate trend. And some functioning RHIOs.”
WOW!!!! Ironic indeed!!! The conclusion after all this: STOP THINKING BIG …Do as little as possible, as slowly as possible...And whatever you do, don't try too hard to change the healthcare system and improve patient care!!! So, this is the “wisdom” of the day: We ought not to try to solve the big problems with patient right yet. We shouldn’t be wasting our time looking for innovative, low-cost ways for exchanging rich clinical information for better care outcomes. We should avoid shaking things up because it might annoy certain providers. After all, providers have other priorities—which focus on maximizing profits—and a consumer-centric approach to increasing value would actually decrease profits in our backward healthcare payment system. Conspicuously absent from this “wisdom,” however, is any mention of changing the system itself to bring greater value to healthcare consumers! How wise is this wisdom? I have to tell you, I’m just sick of this!!! Why do I even bother?!? I’ve been banging my head against an immovable wall for the past 25 years promoting innovative ways to deal with these problems cost-effectively. The response: I’ve been ignored and dismissed, attacked and ridiculed, and accused of self-promotion. I’ve been told repeatedly: “Wait …take it slow …think small …don’t try to change much.” Let’s face it, the healthcare payment system simply isn’t designed to promote care value. Providers who strive to deliver high value care are punished financially. Inefficiency (waste and redundancy) and ineffectiveness (fix it, then fix it again when it breaks) are rewarded, while efficiency and effectiveness are punished. This is why providers are justified in fearing they will go broke if they:
  • Keep their patients healthy through good well-care (including prevention and effective self-management of chronic conditions)
  • Help their patients recover quickly and cost-effectively when they are ill by using clinical decision tools, exchanging patient health information electronically, collaborating and coordinating care in multidisciplinary teams, etc.
  • Spend more time with patients to make sure they understand what their patients need, how they feel, what they prefer, and what they must know.