Flipping the Clinic: On Brainstorming Innovation by Patient Type

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)

It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone’s health needs at the same time?

In other words, are we likely to come up with good ideas when we’re striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple “mundane” chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including “self-healthcare” such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren’t thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we’re a healthcare provider, we’re thinking of the needs of those patients that we spend the most time with, or are most interested in.

Common Types of Patients

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Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here’s what I’ve been thinking about…

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

First of all, I think it’s fair to say that my idea of clinical decision support is different from yours.My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies.

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer.

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on…

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

So we’ve developed a set of checklists for each step in the visit workflow, as well as over the life of the patient.

Here’s an example for how a Medical Assistant rooms a patient, complete with time-study data of how long that has been taking in our practice.

Inline image 2

And while we’d love to code answers to problems, we’re now fighting software with humans. Said differently, we’re actually adding scribes to the workflow as well. It’s hard for a physician to see a patient and manage a checklist…but if someone is in the room with you to remind you to go through the diabetes checklist for all diabetic patients?

And if we have a team to keep those checklists up to date and continuously improving? That might work, and it seems like it is…30% reduction in admissions thus far this year relative to the Cook County average?

We’re starting to call our scribes by a different term as a consequence of all these extra responsibilities. We call them “ninjas.”

So where technology can’t help us with decision support, maybe ninjas can?

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health in Chicago. You can contact him at griffin (at) oakstreethealth (dot) com.

How to Help Families Assess Quality of Care

[This post was first published on The Health Care Blog on 6/27/13, titled How Patients Can Assess the Quality of Their Outpatient Care.]

Even before I launched my geriatric consultation practice, I found myself often poring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.

Sometimes these other doctors were specialists to whom I’d referred the patient. But often they were simply clinicians – either previous PCPs or currently involved specialists — whose involvement with the patient predated my own.

Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.

These are, in truth, legitimate concerns patients have. In a busy outpatient setting, doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values.

So if you are a concerned patient or family member, and you’re not entirely sure about the medical care you’re getting, what to do?

Should you:
  1. Look up the provider’s quality ratings online, through a government, non-profit, or other website?
  2. Figure that the ACO or payer is on top of it, now that we are moving to pay-for-quality and fee-for-value?
  3. See what other patients have said about the provider’s care?
  4. See how many doctors are referring to the provider in question, and assume that if many doctors refer to this clinician, the clinician must be good?
  5. Look up your medical problems online, and try to determine for yourself whether you’d been getting the right medical care?
  6. Get a second opinion from another doctor?

My guess is that most patients and families end up trying one – or both – of the last options. In this post, I’ll explain why I’ve come to believe that facilitating second opinions is integral to empowering patients, and to improving the quality of outpatient care.

Why seek a second opinion

I don’t know about you, but when I’ve found myself trying to solve a problem in which I lacked adequate expertise, I’ve turned to a professional for help. (I haven’t had to do this for medical reasons in the past decade, but have done it for issues such as home renovation and website design.)

And in many cases, after meeting with an expert for a while, I’ve then turned to yet another expert to get an additional perspective on the issue at hand.

Why? Well, how else am I supposed to determine whether expert #1 is providing me with suitable expertise, especially if after seeing expert #1 I’m left with a nagging feeling that maybe this isn’t quite the help I wanted. In my case, the stakes have been my time, money, and satisfaction with the end product. But if it were a question of health and wellbeing, I’d probably be even more diligent about getting a second opinion.

Incidentally, this is how many patients and families now find me. They have been getting care, but they are either dissatisfied, or they’re worried that perhaps not all the right things are being done.

And so even though I’m happy to be a consultant to other doctors, I’m now mainly a consultant to elders and families. And just as I did when I was a PCP, I find myself spending a lot of time explaining to families what other doctors are doing.

This, I think, is good work to be doing. By looking over records and discussing a family’s medical concerns, here are the specific things I’ve found myself doing:

  • Reassuring families that the current medical treatment plan is reasonable. Often, in looking over the care, I find that the medical care so far corresponds to guidelines and common standards of practice. However, in many cases clinicians have not had time to explain their approach in depth to the patient and family. Families are often relieved to hear this, and appreciate developing a better understanding of their usual clinician’s plan.
  • Pointing out which aspects of the care plan are worrisome. Worrisome, as in really not concordant with guidelines or best practice. These include benzodiazepines for sleep in the elderly (with no discussion of the risks, or plan to avoid indefinite benzo use), or failure to initiate workup for an alarm symptoms such as significant weight loss. This also includes failure to follow-through on a plan; I’ve come across some charts in which the PCP repeats the same plan to get labs or pursue a study, at every follow-up visit. (In one case, the patient’s family had no idea that this was the plan.)
  • Pointing out medications, procedures, or other medical interventions that are likely to be of marginal benefit. This comes up quite a lot in frail elderly patients, because many common approaches in general medicine require time to benefit (i.e. statins, tight glucose control). In other cases, clinicians have developed the habit of referring patients for tests that research has shown to not be so helpful, such as screening for asymptomatic carotid stenosis.
  • Pointing out which aspects of the care plan could be considered choice and preference sensitive. There are some things in medicine that definitely should be done. For example, if an older person has a loud murmur and shortness of breath on exertion, he or she should almost certainly be sent for an echo, to evaluate for symptomatic valve disease. But for many other things, especially when it comes to elderly patients – or patients of any age, in truth – there are many possible ways to proceed, all of which could be considered reasonable. Back pain without alarm symptoms? One could refer for physical therapy, or prescribe analgesics. Or do both. Ideally this would depend on the patient’s preferences and particular circumstances. But in common practice it seems to depend more on the style of the clinician.


Why we should make it easier for patients to get second opinions

The main reason to do it relates to last point above: we should enable patients to get a second opinion because often there is no definite right way to proceed medically, and so how to proceed is essentially a judgement call.

And without access to second opinions, it will be very difficult for patients and families to determine which aspects of their medical care involve judgments calls.

Now, in an ideal world, this wouldn’t be an issue because clinicians would be able to consistently let patients know which aspects of the treatment plan consist of judgment calls, and would always offer patients the option of shared decision-making for these situations.

But the real world is different. Most clinicians are not used to presenting patients with options, and then tailoring the care plan to meet the patients’ preferences rather than a clinician’s habits. If nothing else, doing so takes time, and no clinician has much time these days. So judgment calls proceed according to the clinician’s judgment and preferences, in accordance with our time-honored habits of letting doctors decide because presumably they know what’s best for the patient.

Except, they often really don’t know what’s best, or even better. Among other issues, in many cases clinicians have not had the time or inclination to develop a good understanding of the patient’s experience. To quote from Dr. Larry Weed’s “Medicine in Denial”

It is the patient, not the physician, who must live with the risks, the pain, the trade-offs, the effort and time that decisions may entail.

On their own, patients experience pain and effort. But they may not be aware of trade-offs, risks, and alternative options. For that, they need more information, and although some of it can be found through diligent searching online, they should also be able to access an expert who can synthesize information and tailor it to the situation at hand.

In this way, patients and families can be empowered to check on the quality of their care, and can identify other courses of medical treatment may be a better fit for them.

Barriers to second opinions and how to overcome them

There are, of course, some barriers to making high-quality second opinions more easily available to patients. They include:

  • Difficulty accessing patient data and bringing it to another clinician. My own work is often held up by the effort of obtaining records and information from other clinicians. Patients should be able to access and collect their own healthcare data, as this will facilitate care coordination and empower patients to participate more in their own healthcare. (Give ‘em their damn data!) But until this is widespread, the challenges of health information exchange make it hard to have another clinician weigh in on one’s care.
  • Inadequate clinical documentation. Even when one manages to get information from another clinician, it’s usually quite hard to tell what the clinician was really thinking or planning to do. Before templated EHR notes, the problem was that notes were very short and uninformative. (See Larry Weed’s 1971 grand rounds for a hilarious and biting critique of clinical documentation. Sad to say that things have not yet improved much.) Now that EHRs provide templates, I receive notes with lots of text and still have no idea what is going on. Plus some of the information is quite frankly wrong, presumably because the clinician has checked too many boxes in a hurry.
  • Difficulty accessing and identifying a suitable expert. Even when patients have gathered the right medical information, they may often find it difficult to access someone for a second opinion. Academic clinics often have long waits for an appointment. Clinicians who are not subsidized by a larger institution may not offer appointments that are long enough to allow for review of a complicated medical situation.

Summing it up

Second opinions can help patients and families check on the quality of their care, in real-time. This can reduce a family’s anxiety about ongoing medical care, and can help patients better understand the care they’ve been receiving.

Although occasionally real gaps in care are uncovered, in my own experience I’ve found that second opinions mainly help patients and families identify other management approaches which their previous clinician may not have discussed with them. For older patients in particular, care should be individualized and tailored to the patient’s – and caregivers’ — needs and preferences. Historically clinicians have tended to dictate care according to their own habits and preferences, in part because shared decision-making takes more time. Second opinions can help educate patients, and empower them to better individualize their care.

Barriers to faciliating second opinions include difficulty accessing clinical information in the possession of other providers, as well as inadequate information within the progress notes. Last but not least, patients may currently find it difficult to find a provider willing and qualified to provide a second opinion.