Tuesday, May 26, 2009

Employees tough to budge on workplace health

I was recently interviewed by an Australian organization called Return to Work Matters. It is directed by leaders in occupational medicine, return to work facilitation, policy development and support for professional networks. They have an interesting and informative web site at http://www.rtwmatters.org/index.php. Following is a copy of the interview, which also appears on the rtwmatters.org web site.

Who is least likely to participate in workplace health and wellbeing programs and why?

People who ignore or deny their health problems and risks are least likely to participate. That’s often because they have psychological “blocks” that drain their energy and willingness to focus on self-care and self-improvement. The blocks may be due, for example, to underlying depression. This depression, in turn, causes people to:

  • Sleep too little or too much
  • Be unable to concentrate
  • Feel worthless and hopeless
  • Lose their appetite or be unable to stop eating
  • Have low frustration tolerance
  • Become easily irritated and angry
  • Even have self-destructive thoughts that they’d be better off dead.

For others, it may be anxiety and self-doubt, which leads to them denying that they have a problem. That’s because many people tend to convince themselves they don’t have a problem if they feel anxious thinking about it, or if they doubt they can improve the situation. While this coping strategy can relieve the anxiety temporarily, it is maladaptive because it does nothing to improve their situation and actually leads to worsening health by failing to manage the problem effectively.

People hampered by these psychological blocks are also less likely to be motivated by rewards and punishments because their failure to participate in a workplace health program is not due to laziness. These examples evidence a strong mind-body connection when it comes to self-managing one’s phsycial health and emotional wellbeing.

Here’s another thing to consider. Improving employees’ health and wellbeing requires lifestyle and psychosocial factors. Examples of psychosocial factors that affect return to work area include developing healthier behaviours (e.g. eating, exercising, sleeping and following doctors’ orders for managing existing conditions), as well as more adaptive emotions, rational thinking and effective coping skills.

That means employees must be able to continue making the positive changes after they leave work. As such, they must have the time, money, transportation and social support necessary to buy healthy foods, exercise adequately, get enough sleep, take required medications, control their stress and deal with personal problems.

What are the key things employers need to consider when planning and implementing a workplace health program?

In addition to health education, employers ought to have in place adequate resources—tools and people—to assess and deal with the psychological blocks I just mentioned. These resources include good mind-body health status assessments, as well as wellness coaches and counsellors. In addition, it can be beneficial to get the family of a resistant employee involved in the program as a means of social support. It’s also important to measure the program’s effectiveness in terms of enrollment and drop-out rates, as well as progress toward meeting participants’ health goals. And it’s important to measure a program’s performance and have a plan for continually improving its efficiency and effectiveness.

What do employers tend to forget about in terms of workplace health?

Employers tend to forget that punishments, incentives and threats do not work for everyone. Many people need compassionate counselling and a flexible program that addresses both their physical AND psychological needs.

What are the most effective methods for motivating employees who seem to have no interest in health and wellbeing?

They need a powerful reason to change their lifestyle despite the psychological blocks. Research has shown, for example, that ‘joy of living’ is a much more powerful motivator than ‘fear of illness and death’. Likewise, having self-confidence, being hopeful, alleviating depression and anxiety, learning to handle stress effectively and thinking rationally are factors associated with motivation.

Counselling is the best way to emerge these positive psychological characteristics in people lacking them by guiding changes in the way they think, feel and behave.

What suggestions do you have for organisations which lack the budget for health counselors?

One possibility is for employees with psychological blocks to receive psychotherapy outside the workplace, which has health motivation as a primary goal. Another possibility is to use cognitive-behavioural therapy self-help software, web sites and books.

In fact, I’m developing a holistic personal health record with a self-help component that incorporates cognitive-behavioral counselling and structured problem solving. This interactive software application helps guide a person to deal with health and other personal problems by understanding and changing their maladaptive thoughts, emotions and behaviours, which develops more effective coping skills.

Please tell us a bit about what keeps you passionate about workplace health.

My life mission is to help people across the globe lead healthier, happier and more productive lives. Workplace wellness programs have an important role to play in realising this goal.

Friday, May 15, 2009

Patient-Centered Medical Home: Gaining Traction

I want to commend the National Committee for Quality Assurance (NCQA), the American Academy of Family Physicians (AAFP), and other physician-based organizations involved in writing the Standards and Guidelines for Physician Practice Connections®—Patient-Centered Medical Home (PPC-PCMH™), which is available at this link.

I first wrote about the medical home concept in 2006 as being a key component for our healthcare crisis at this link. I followed it up in 2007 with a blog post at this link and then again in 2008 at this link.

The joint principles of the PCC-PCMH are:
Personal physician—Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice—The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation—The personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services and end of life care.
Care is coordinated or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home.
  • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients and the patient's family.
  • Evidence-based medicine and clinical decision-support tools guide decision making.
  • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision making and feedback is sought to ensure patients' expectations are being met.
  • Information technology (IT) is utilized appropriately to support optimal patient care, performance measurement, patient education and enhanced communication.
  • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
  • Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. While aspiring to improve patient care, the four primary care groups envision implementation of the PCMH as linked to more rational (and higher) payment for primary care, which is in very fragile status in the U.S. The four primary care groups, aided by others, have held discussions with employers, health plans and the federal government to encourage the development of PCMH implementation/demonstration programs. In concert with the joint principles, the PPC-PCMH standards emphasize the use of systematic, patient-centered, coordinated care management processes.
These principles are both sound and doable! After seeing many good ideas evaporate due to lack of will and competing interests, I'm encouraged that strategies such as the patient-centered medical home are finally gaining real traction.

There are critics, however. For example, a recent article, titled Effectiveness of medical homes questioned, discussed how the “…effectiveness of medical homes as a tool for improving care was called into question at a hearing of the Senate Health, Education, Labor and Pensions Committee…[because of] ‘concerns about how to best design and implement such a model’…Some believe requiring physician referral for specialty services under a medical home model might introduce a costly and needless step to linking patients to the right source of care [arguing that] primary care is not always the most cost-efficient and effective provider for every condition and disease.”

I agree that critical evaluation of all healthcare delivery models (including the patient-centered medical home) is a good thing. But I do not agree with the criticism that primary care physicians (PCPs) may not be the best people to manage care coordination, even though certain PCPs will likely do a better job than others in coordinating care. As a group, however, PCPs, being generalists, seem to me to be the ones best suited for the job. Nevertheless, it’s important that our healthcare system enable PCPs to provide this crucial service by supplying them with effective health IT tools and paying them enough to spend the time necessary to coordinate and evaluate care being rendered to their patients. Over the long term, this will likely save money, especially when treating patients with chronic conditions, by eliminating duplication of tests and having multidisciplinary teams collaborating effectively.

Related links:

Saturday, May 02, 2009

Toward a Meaningful Definition of Meaningful Use (part 1 of 2)

The federal government's $20 billion stimulus programs for health IT (HIT) is on its way. Called HITECH—for Health Information Technology for Economic and Clinical Health Act—it will fund the development of innovative HIT and use a "carrot & stick" financial approach to encourage clinicians to use HIT in meaningful ways. A debate now raging is how to define "meaningful use."[1] 

A Definition

Meaningful use, to me, means using HIT in ways that are of great value to the patient and other healthcare consumers. It doesn't matter what types of software tools are used, what communication infrastructure is used, what standards are used, or what certifications are used. It just means that the using HIT should result in ever more effective and efficient (i.e., ever greater value) care delivery.

Increasing care value is unlikely unless clinicians obtain information and guidance assisting them in answering difficult questions, making tough diagnostic and treatment decisions, collaborating effectively, and taking competent action. In addition, healthcare consumers (patients, clients, customers, etc.) would benefit from assistance in selecting the most cost-effective treatment options for existing conditions, and in managing their own health in ways that prevent illness, control chronic conditions, and increase their well-being.

Such assistance is crucial because the unaided human mind simply cannot handle the overwhelming details and complexity of many health problems. Consider the following section which contains important quotes from Dr. Larry Weed and others:

The volume of clinical information expands exponentially with more than 150,000 medical articles published each month in more than 20,000 biomedical journals. Healthcare providers struggle to stay current with the clinical information, but inevitably become overloaded. This may contribute to the slow adoption of evidence-based research in clinical practice. There is just too much clinical information being generated for providers to incorporate into their internal base of knowledge.
As a group, healthcare providers care about patients and take pride in doing an excellent job in caring for their well-being. Nevertheless, the "…task of knowing every detail is way beyond the [ability of] human mind… For example…diabetes care ought to take into account any of 120 management options and 380 possible patient conditions associated with the disease. …the unaided mind cannot reliably recall all the causes or management options that should be considered for each patient, nor can it recall all the findings in the patient needed to discriminate among those options, nor can it reliably match findings to options under the time constraints of practice."
In addition, "…most physicians are able to take into account only a portion of the diagnostic and management options potentially relevant to their patients and only a fraction of the evidence needed for choosing among those options. …Physicians do little better with the usual aids to medical decision making, such as practice guidelines and use of Internet resources. Those aids provide general knowledge, but do not ensure that the physician will recall all the data or successfully link it with a particular patient's specific problem." Problems that cross specialty boundaries and require multiple specialists, yet the current healthcare system does a poor job at supporting communication between providers and assuring continuity of care. And primary care physicians are not equipped with the information tools necessary to grapple with the information overload, nor do they have a system for coordinated care within which to function.
"Because physician time is expensive and scarce, their initial workups can be meager [as they] …act according to their own preconceived notions about what history, physical, and laboratory findings are worth checking. Equally idiosyncratic are the conclusions they draw from whatever data they select. Both selection and analysis of data are influenced heavily by their medical education, prior clinical experience, specialty orientation, contradictory clinical guidelines, financial concerns, cultural background, personal biases, and day-to-day time constraints, all of which vary enormously among individual practitioners."
With this in mind, consider the recent report by the National Research Council of the National Academies, which concluded that a serious gap in health information technology (HIT) today is the failure to deliver patient-centered cognitive support (also called consumer-centered cognitive support). According to the report:
During the committee's discussions, patient-centered cognitive support emerged as an overarching grand research challenge to focus health-related efforts of the computer science research community, which can play an important role in helping to cross the health care IT chasm...Today, clinicians spend a great deal of time and energy searching and sifting through raw data about patients and trying to integrate the data with their general medical knowledge to form relevant mental abstractions and associations relevant to the patient's situation…The health care IT systems of today tend not to provide assistance with this sifting task…[We need] computer-based tools [that] examine raw data relevant to a specific patient and suggest their clinical implications given the context of the models and abstractions. Computers can then provide decision support—that is, tools that help clinicians decide on a course of action in response to an understanding of the patient's status. At any time, clinicians have the ability to access the raw data as needed if they wish to explore the presented interpretations and abstractions in greater depth…The decision support systems would explicitly incorporate patient utilities, values, and resource constraints…They would support holistic plans and would allow users to simulate interventions on the virtual patient before doing them for real.[2]
It's logical to conclude from the information above that patient-centered cognitive support is the kind of value-enhancing assistance needed, but largely missing from, today's HIT.

Thus, "meaningful use of HIT" can be translated into "using HIT to increase care value (efficiency and effectiveness) by providing ever-better patient-centered cognitive support."

The HIT Gap and How to Fill it

Is it reasonable to expect the healthcare industry to fill the patient-centered cognitive support gap? According to a recent report by the Congressional Budget Office titled, Evidence on the Costs and Benefits of Health Information Technology,[3] HIT systems have the potential to provide such cognitive support by, for example, reminding physicians to schedule tests, helping them diagnose complicated conditions, assisting them in implementing appropriate treatment protocols, and promoting research focused on developing and evolving evidence-based guidelines.

A Different Definition from HIMSS 

While I proposed a path of radical HIT innovation, the Healthcare Information and Management Systems Society (HIMSS) Board of Directors recently proposed a more conventional path, which includes these seven HIT requirements:
  • EHR certification by the Certification Commission for Healthcare Information Technology (CCHIT)
  • Standardized patient data conforming to the Healthcare Information Technology Standards Panel's (HITSP)
  • Interoperability specifications based on the Integrating the Healthcare Enterprise's (IHE) frameworks
  • Use of an EHR including CPOE (computerized practitioner order entry) functionality
  • Electronic exchange of patient summary information as specified in the Continuity of Care Document (CCD) standard
  • Support for a subset of existing National Quality Forum-endorsed process and care measurement
  • Use of clinical decision support (CDS) systems providing clinicians with clinical knowledge and intelligently-filtered patient information to enhance patient care.[4]
Interestingly, only item #7 relates directly to the delivery and continual evolution of patient-centered cognitive support, even though it barely scratches the surface as to what a CDS system should do. And while item #6 is also important, the subset of measures is grossly inadequate for delivering and evolving patient-centered cognitive support. Furthermore, it doesn't push for significant implementation until 4-7 years from now.

Item #1 refers to an expensive certification process that stifles radical innovation by forcing out small HIT companies, including open source developers. I can see the benefit of testing HIT vendors product to see how good they work (like Consumer Reports does with cars and appliances), but vendors shouldn't have to pay for it (Consumer Reports doesn't make the manufacturers pay). Instead, a government agency (FDA?) could probably do it. Furthermore, the certification process to which HIMSS refers has nothing to do with patient-centered cognitive support.

Items #2 & 3, which refer to data and technology standards, present a double-edged sword for reasons I discuss in a series of posts starting at http://curinghealthcare.blogspot.com/2007/05/art-of-health-knowledge-creation-use.html. Rather than limiting HIT developers to a specific set of global standards, it would be better to allow them to use local data standards and any technology standards, as long as their tool can exchange required information with tools other vendors develop. That's because well-designed innovative HIT tools should be able to provide patient-centered cognitive support without the constraints of particular data and technology standards.

Items #4 & 5 refer to particular types of HIT, which I agree are important. The problem with making exiting EHRs, CPOEs, and CCDs a requirement for "meaningful use" is (a) the current crop of HIT provides little, if any, patient-centered cognitive support and (b) this constraint may hamper innovation by impeding the invention of alternate types of HIT able to provide superior cognitive support.


HIT is used meaningfully if it focuses on increasing care value (efficiency and effectiveness) to patients and other healthcare consumers by providing ever-better cognitive support. The smart path to meaningful HIT use is one that promotes the kinds of radical innovation that enable widespread collaboration and the application of good science focused on providing continually evolving patient-centered cognitive support. Following this path means (a) accepting that the unaided human mind, no matter how competent, simply cannot handle the incredible amount of complex information that must be processed to make wise decisions in difficult situations, (b) doing more to link scientific research and clinical practice, and (c) encouraging truly creative HIT solutions. 

The discussion is continued at this link.

[1] http://www.lexuniversal.com/en/news/7764
[2] Stead, W.W. and Lin, H.S. (Eds.) (2009). Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council from http://www.nlm.nih.gov/pubs/reports/comptech_prepub.pdf
[3] Congressional Budget Office. (2008, May).
Evidence on the Costs and Benefits of Health Information Technology. Retrieved from http://www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf
[4] http://www.himss.org/ASP/ContentRedirector.asp?ContentID=69148&type=HIMSSNewsItem