primary care

Case Study Part IV: What Joan Really Needs From Her Healthcare

September 14, 2015

Today, I’m going to share the fourth and final part of my case study about Joan, a 79 year old woman struggling to manage her many chronic conditions.

I created this case study for my upcoming ebook, because over the years I’ve noticed that different people can have very different perspectives on a single person’s health challenges.

So in the book, I cover the perspective of Joan herself, the perspective of Joan’s worried family caregiver, and then the viewpoint of Joan’s primary care provider, Dr. Miller.

But of course, there’s one more perspective that’s essential to consider, if you are developing tools to help people with their health. That’s the external “expert” analysis and perspective, which I share below.

When it comes to healthcare — or anything important — we can’t assume that front-line users know just what is best, and what’s most likely to help them achieve their goals. That’s why truly useful tools must facilitate “best care,” or at least better care. Here’s what that could look like for Joan.

What Joan Really Needs From Her Healthcare

Dr. Miller’s not a bad doctor. But he’s busy, he’s under pressure to meet quality measures, and he hasn’t been trained to modify healthcare for older adults.

Like many doctors, he’s pretty focused on Joan’s documented health diagnoses. But what Joan really needs is for someone to help her with her health problems. I’d list these as follows: [Read more…] about Case Study Part IV: What Joan Really Needs From Her Healthcare

Case Study Part III: The PCP’s View on Joan’s Health

August 28, 2015

People often wonder why doctors aren’t more interested in apps for their patients, or in trying something new to help patients. After all, we expect doctors to care about their patients’ health.

Plus, we know that doctors are now being held more accountable for outcomes, because we’re moving towards “pay-for-value.”

I do believe that most doctors care about their patient’s health. But it’s not easy being a PCP, and there are lots of reasons that the average PCP has difficulty optimizing the health of a medically complex senior.

Here is part III of the case study I created for my upcoming ebook: the point of view of Joan’s PCP, Dr. Miller. As you read, consider

What’s the doctor focusing on when it comes to Joan’s health? How does that align with what Joan herself is most concerned about, and what her daughter is concerned about?
What kinds of tools or services might help the PCP with what he’s trying to do for Joan’s health?

And for extra credit: what’s he overlooking that someone applying geriatrics — the art & science of modifying healthcare so it’s a better fit for older adults — probably would address? (Hint: it’s related to Joan’s vitals.)

Joan’s Health Story (According to Her Doctor)

7 Types of Help People Want from Healthcare

February 6, 2015

What do people want from their health care, and their medical care?

In my last post I shared a rough taxonomy of patient types, based on stage of life and type of chronic health problems.

Similarly, I think it’s useful to sketch out the types of help that people seek from the healthcare system. So far I’ve come up with seven.

But before I share them, let’s step back and consider the big picture of health care.

What’s the point of health care and our healthcare system?

The overarching purpose of health care, and the overall thing people want from healthcare, is:

To optimize the ability to participate in life, today and in the future.

This is the underlying reason that people want help with their health.

(What is health? See my practical definition here, and yes I’m still hoping for feedback on it!)

Just what it takes help optimize a person’s abilities depends on the details of their health situation. For instance, for a person who has recently suffered a stroke, it might be things like speech therapy and physical therapy to optimize function, adaptive equipment and home modifications to facilitate getting around safely, treatment of post-stroke depression, and medical management to reduce the risk of a future stroke.

7 ways the healthcare system helps people with their health

Flipping the Clinic: On Brainstorming Innovation by Patient Type

January 23, 2015

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

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

August 22, 2014

[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.