GeriTech

In Search of Technology that Improves Geriatric Care

primary care

Capturing Data to Improve Medicare Primary Care: The Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]
Forgive the brief hiatus: we’ve been busy with a growing
patient community and plans for taking our model to new neighborhoods.
We left
off last time with a discussion of infrastructure, and today we’ll transition
to what that infrastructure can do. Again from the Institute of Medicine report
“Best Care at Lower Cost: The Path to Continuously Learning Health Care inAmerica,” here is the next of the 10 recommendations.
Recommendation 2: The data utility. Streamline and revise
research regulations to improve care, promote the capture of clinical data, and
generate knowledge.
The most common source of data used in healthcare today is
claims data. This generally includes (1) patient indentifiers, (2) CPT codes
(i.e., billing codes), and (3) corresponding ICD codes (i.e., diagnoses to
justify the services billed). Together those create a matrix of who has what
medical conditions and the list of interactions with the healthcare system they
have to manage those conditions. 
These data are provided by payers and are
useful in understanding if a particular patient received a particular
intervention. For example, payers can tell which women aged 42 to 69 had a
mammogram during the previous 2 years. For us, that’s an important Medicare
metric that we can use to make sure patients get the right preventive services.
It’s a great start, but we want to go further.
At Oak Street, we have a hypothesis that structured,
clinically relevant, validated data has more predictive power than claims data
alone.(Think Lawton and Katz functional scores, PHQ-9 depression scores, etc.) So we work hard to create that data in each of
our interactions. We structure our charts so the data that goes in is usable.
(Think fewer text boxes, more numbers and drop-downs, etc.)
Deciding what to structure is nontrivial. Do you want
structured data for labs and vitals? Yes. How about medications and allergies?
We do. Timed-get-up-and-go scores? Probably. And bowel sounds? Probably not.The
ultimate goal of all of this is to make care much more systematic. We want to “triage”
patients so we know who needs the most attention now. We
want to flag errors and gaps: the system should tell us which patient needs a
colonoscopy…I don’t want to leave that to an individual.
Of course, this description feels like a technology project,
but it’s really more than that. It’s about training and creating a culture
where the whole team is proud of the data we create. That’s hard, and we work
on that every day.
As you can see, this “foundation” is no small task. Are we
perfect? Not close. But we did start with a focus on the digital infrastructure
to run a practice and utilizing data to do some creative things to take really
good care of older adults. The tools to do this will only get better with time,
and we hope our structured processes can fill in the gaps in the meantime.
Griffin Myers, M.D., M.B.A. is a founder and the Chief
Medical Officer at Oak Street Health in Chicago. He is currently in his final
year of an emergency medicine residency in Boston. You can contact him at
griffin (at) oakstreethealth (dot) com.
Disclosures

The author wishes to disclose a financial interest in the
primary care model discussed above. Furthermore, he is a trainee in a
postgraduate clinical training program, and neither the program nor the
affiliating university endorses, owns, or has any formal or informal
relationship with the primary care model.

Medicine in Denial: The Problem-Oriented Medical Record

[This post, which was first published on The Health Care Blog on 5/10/13, is Part 2 of a commentary on “Medicine in Denial,”(2011) by Dr. Lawrence Weed and Lincoln Weed. You can read Part 1 here.]

An excellent chapter in “Medicine in Denial” discusses the problem-oriented medical record (POMR), a comprehensive charting approach that Dr. Larry Weed began developing in the late 1950s.
The Weeds begin by detailing what a good health care record should allow clinicians, and the healthcare system to do. In other words, they start by clearly defining the needs of patients, the purpose of the medical record, and the kind of health care it should support.
Specifically, the Weeds make the following points:
  • Managing chronic illness often involves multiple interventions that require adjustment over time, rather than a single treatment that results in cure/resolution. This requires tracking of physiologic variables and medical interventions over time.
  • Chronic care of medically complex patients, especially those with multimorbidity, requires coordination of care among multiple clinicians at multiple sites over time.
  • For the many people suffering from multi-morbidity, chronic medical problems and their associated interventions often interact. This makes it particularly important that care be individualized, and carefully tracked over time.
  • Enabling patient awareness, participation, and commitment is essential, with the Weeds noting that “unavoidable complexity must somehow be made manageable by patients who need to cope with what is happening to their own bodies and minds.”
  • Patient care – and hence the charting of medical data — must be oriented towards a single purpose: individualized medical problem solving for unique patients.
In other words, the Weeds consider the longitudinal, comprehensive, person-centered, individualized, collaborative care of the medically complex patient to be a fundamental base scenario around which we should design healthcare, and healthcare information systems.
This left me deeply impressed, since most of what I read about changing healthcare seems to treat the primary care of medically complex patients as an afterthought, or special use scenario, rather than as the starting point from which we redesign our healthcare tools.
Also impressive to me was the way the Weeds consistently put the involvement of the patient front and center in their thinking:

“[Informed patient] involvement requires external standards and tools that patients themselves learn to use, both independently and jointly with their providers. Without that patient involvement, unnecessary complexity and fragmentation occur, as multiple providers intrude on inherently personal decisions that patients are better positioned to manage for themselves.”

Wow. It’s one thing to breezily advocate for patient engagement, and another to work out a healthcare framework that is designed to maximize the patient’s ability to meaningfully engage in, and individualize, his or her own care.

A medical record designed for individualized comprehensive care over time

“The medical record is critical for complex cases involving chronic disease and multiple problems, which is where the largest amount of healthcare resources are consumed.”

Having laid out their priorities, the Weeds state that the key to managing medically complex patients over time is to “use the medical record to organize the myriad processes of care around defined patient needs.”
Organization and order in the medical record is key, of course. The Weeds outline the following core four components for the POMR:
  • A defined database of information, to store the relevant information that has been gathered;
  • A problem list, with problems defined in terms of the patient’s needs;
  • Plans of action for each problem, developed in light of the other problems;
  • Progress notes on each problem, which document the process of following up, including gathering of feedback and adjusting the plan over time.
Importantly, the Weeds consider psychosocial problems to be significant, and say they should be included in the problem list. They also describe the creation of a patient profile describing the patient’s family and living situation, noting that “these data are essential for the practitioner to understand the patient’s ability to cope with medical problems and to work realistically with the patient in setting goals and planning for diagnosis and management.”
Advocates for patient-centered care, take note!
How to actually use the POMR in practice? The Weeds write:

“A problem-oriented structure requires that all practitioners record each plan and progress note by the specific patient problem to which it relates. The patient’s total medical situation is summarized by a complete problem list appearing at the first page or screen of record…Enforcing the POMR standard means that individually relevant information is collected, considered, and acted upon by all practitioners and the patient over time, with the patient’s total situation taken into account every step of the way.”

Hm. Although I think we can and should do a much better job of following up on patients’ problems over time, I found myself wondering how exactly the POMR can ensure that all problems are considered when making a plan for a specific problem.
For instance, many elderly patients have 15-20 items on their problem list, and they would probably have more if providers were comprehensive and documented everything that is a problem for the patient (issues such as sleep, pain, and falls are often underrecognized).
Even if we work with a chart that makes it possible for us to view a comprehensive problem list, it’s still a significant cognitive challenge to hold all those factors in one’s mind as one considers options for moving forward on a particular problem. And what do people tend to do when faced with cognitive effort? They tend to avoid it, especially if they are rushed, tired, or stressed. (Read the work of Daniel Kahnemanand others if you are skeptical.)
Now, clinicians are of course capable of putting forth cognitive and emotional efforts, but realistically, it’s very difficult to sustain such focus during several back-to-back visits.
Hence, I found myself feeling a bit the same about the POMR as I did regarding the Weeds’ ideas on standardized inputs and knowledge coupling: sounds like an excellent idea in theory, but also sounds labor-intensive and more than a little challenging to implement under current practice conditions.
This isn’t to say we shouldn’t seriously consider using the POMR. The Weeds are entirely correct when they point out that the failure to follow-up on problems is a serious, endemic problem with grave repercussions for patients and society. Especially when it comes to older patients with multiple problems, it can be very easy for problems like depression, incontinence, falls, or memory complaints to fall through the cracks as clinicians gravitate in a rushed visit to tinkering with blood pressure or diabetes management.
And we would almost certainly be providing better care over time if our charting methods made it possible to easily see how a given problem had been managed over time. For instance, in many cases, it’s actually quite difficult to find out how a patient’s high blood pressure or other chronic condition has been managed over the past few years. What medications have been tried and why were they changed? What related tests were done? We often find ourselves asking the patient for this information, or worse yet, not even taking the time to ask these questions because time is so short.
As the Weeds note:

“Without well-structured progress notes, clinicians can easily fail to recognize trends and correlations in data, lose track of significant test results, fail to consider interactions among multiple problems, or fail to coordinate their activities with other practitioners. These failings occur particularly with chronic illness.

So true.

The organized clinician’s guide to making a plan, and engaging patients

In line with their orderly bent, the Weeds’ POMR model includes detailed suggestions as to how to document the plan for each problem. They propose the following element set for initial management plans:
  • Basis: this refers to the abnormalities/complaints that are evidence for the problem
  • Status: whether the problem is getting worse, better, or staying the same
  • Disability: this requires understanding the problem’s significance from the patient’s perspective (!)
  • Goal: this should be articulated after conversation with the patient and after considering all other problems affecting the patient
  • Follow course
    • Parameters to monitor course and status of problem
    • Parameters to monitor response to therapy
  • Investigate further
    • Hypotheses to be investigated
    • Measures to investigate each hypothesis
  • Complications to watch for
I found myself yet again impressed. Does your doctor do this when they diagnose you with a medical problem? I wish I could be doing this for my patients, but the truth is I often just rely on my brain to try to cover all these angles. Which means I’m not as consistently thorough as I’d like to be.
The element set above also struck me as a genuinely useful framework to support today’s all-important theme of “patient engagement.” To begin with, consistently documenting disability and goals would go a long way towards getting clinicians to understand medical problems from the patient’s perspective.
Then there’s the explicit outlining of the plan to follow the problem, further evaluate it if needed, and the complications to watch for. Imagine what an impact OpenNotes could have, if the notes being opened contained information such as this.

Why aren’t we using the POMR?

The Weeds’ description of the benefits of POMR sound terrific, so how is it that this approach is not yet in widespread use? After all, Dr. Weed developed this framework decades ago, and although the SOAP note remains in wide use, the comprehensive POMR approach itself seems to never have taken off. (I’m a bit embarrassed to admit that despite my long-standing interest in comprehensive primary care, I’d never even heard of Dr. Weed and the POMR until I researched this post
In “Medicine in Denial,” the authors posit that the POMR was never fully embraced because “the disciplines that the POMR imposes are alien to the culture of medicine,” which prefers to allow provider judgements to reign and the personal habits of providers to dictate care.
This strikes me as true, but feels insufficient as an explanation. I found myself wishing that the Weeds would’ve more clearly outlined some additional current obstacles to implementing the POMR approach in the outpatient setting.
Aside from the cultural expectations that physicians have regarding their work, the main obstacles I see to using POMR in primary care for Medicare patients are:
  • Insufficient time allotted to provide care to each patient. Even with a smart POMR-ready EHR system that properly organized information by problem, I’d expect each encounter would require at least 30 minutes of physician time, if not much more.
  • Insufficient financial incentives to practice comprehensive, person-centered, individualized, collaborative care over time. Unless you focus on a population of high utilizers with “ambulatory sensitive conditions,” a POMR approach seems unlikely to reduce hospital and ED utilization enough to keep the ACOs happy.
In other words, even if physicians were to accept that there’s a need for order and structure, I expect it would still be very difficult for them to implement a POMR approach.
Unless, of course, patients were to demand it en masse. Who else has more to gain than the patients and families?
Advocates for patient-centered care, take note!
[Read Part Three of this commentary on “Medicine in Denial” .]

An Indecent Proposal

[This post was first published on The Health Care Blog on 4/16/13, where they titled it “An Indecent Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week.” It has generated many interesting comments. I post it here with its more modest original title. This post is about recruiting and retaining doctors to work in primary care for medically complex elders.]


A
few weeks ago, The Health Care Blog published a truly outstanding commentary by
Jeff Goldsmith, on why practice
redesign isn’t going to solve the primary care shortage. In the post,
Goldsmith explains why a proposed model of high-volume primary care practice —
having docs see even more patients per day, and grouping them in pods — is
unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer
patients. He points out that we are replacing a generation of workaholic boomer
PCPs with “Gen Y physicians with a revealed preference for 35-hour
work weeks.” (Guilty as charged.) Goldsmith ends by predicting a
“horrendous shortfall” of front-line clinicians in the next decade.
Now,
not everyone believes that a shortfall of PCPs is a serious problem. 
However,
if you believe, as I do, that the most pressing health services problems to
solve pertain to Medicare, then a shortfall of PCPs is a very serious problem
indeed.
So
serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with
a 35 hour work week.
I
can already hear all clinicians and readers older than myself harrumphing, but
bear with me and let’s see if I can make a persuasive case for this.

The crisis we face

First,
consider the situation:
The most
pressing and urgent health services research problem society must solve is how
to restructure healthcare such that we can provide compassionate, effective
healthcare to an expanding Medicare population, at a cost the nation can
sustain.
This
is a problem with very high human stakes at hand. As we know, most older adults
end up undergoing considerable health-related suffering at some point, with
family caregivers often being affected as well. Much of this is due to the
tolls of advancing chronic diseases, such as diabetes, heart disease, COPD,
arthritis, dementia. (See this handy CMS
chartbook for the latest stats on chronic disease burden in the Medicare
population.) And a fair part of the suffering is inflicted by the
healthcare system itself, which remains ironically ill-suited to provide
patient-centered care to those medically complex older adults – and their
caregivers — who use the system the most.
Needless
to say, the financial stakes are high as well, with projected Medicare
expenditures usually cited as the number one budget buster threatening the
nation’s financial stability over the next 50 years.

A necessary part of the solution

Next,
consider an essential component to compassionately and effectively meeting the
healthcare needs of the Medicare population:
Medicare
beneficiaries – and their family caregivers – must be partnered with good PCPs
who can focus on person-centered
care, and can collaborate with them as they navigate the many health
challenges of late life.
Especially
once they are suffering from multiple chronic illnesses and/or disability,
seniors – and their families — need a stable relationship with a clinician who
can fulfill the role of trusted consultant and advisor as they go through their
extended medical journey. Healthcare for older adults almost always becomes
complex and stressful for seniors and their families. Even educated and
activated patients who are willing and able to direct their own care will need
a generalist who can maintain a longitudinal health dialogue with them, and who
can help them sort through complicated medical situations as they arise.
Now,
much as been made of teams in primary care, and the importance of moving past
our historic model of PCP as the person who knows it all, and does it all. This
change is long-overdue, and I’m thrilled to see it coming. When properly
implemented, I’m quite sure that team-based care will help older adults obtain
the comprehensive primary care services they need and want.
But
even with excellent team-based care, I believe most older adults will want and
need a PCP to function as their high-level medical strategy consultant and
collaborator.

Common challenges for PCPs of older
adults

For instance, consider the kinds of issues I routinely addressed as a general internist for older adults:

  • Following up on 6+ chronic conditions and 12+ medications, in an integrated whole-person fashion. Good luck outsourcing this to disease management.
  • Following-up on the work of multiple specialists, many of whom hadn’t explained their thinking to the patient and family. Yes these specialists should get better at explaining their thinking. No, they will probably not resolve the conflicts between their recommendations and some other specialist’s recommendations.
  • Resolving the conflicts inherent in attempting to follow clinical practice guidelines in patients with multiple conditions. For a fun read on how elderly patients routinely generate a gazillion conflicting clinical practice guidelines, read this JAMA article.
  • Adjusting care plans as a function of goals and what seems feasible for the patient. It is pointless to recommend chronic disease management per best practices if it doesn’t seem feasible to the patient and family. Also, many disease management approaches must be modified in the face of conditions such as dementia, cancer, advanced COPD, etc. I’ve spent my fair share of time taking diabetics with mild dementia off sliding scale insulin regimens. (Hello endocrinologists, please stop recommending labor-intensive blood sugar management.)
  • Explaining why certain commonly requested interventions – antibiotics, diagnostic tests, specialty consults – might not be helpful. People have questions. Answering questions takes time and attentiveness. It’s obviously much easier to rely on the historic approach of doctors and just tell people what to do, but that’s not good care.
  • Helping patients and families prioritize and identify a few key health issues to work on at any given moment. Many older patients have 15+ items on their problem list. Prioritizing is key. (Not losing track of all the issues is hard though.)
  • Helping patients and families evaluate the likely benefits and burdens of possible medical approaches. Should that lung nodule be biopsied? Should knee replacement surgery be considered now, or still deferred? So many of the decisions we face have no clear right answer.
  • Helping patients and families cope with the uncertainties of the future. For instance, it’s impossible to predict how quickly someone with dementia will decline and become unable to live at home, but these issues are of grave concern to families and they need a clinician to talk to.
  • Addressing end of life planning. I’ve found this is often trickier in the outpatient setting than on an inpatient palliative care service.
  • Weighing in on family conflicts. I’ve often watched patients and spouses squabble in the visit over what the patient is and isn’t able to do. Similarly, adult children worried about a parent will call and ask for me to intervene. (Stop her from driving! Make him take his pills!)
I
must say that I love doing the work above. It’s deeply satisfying to help
patients make sense of all that is medically happening to them, and to support
them as they cope with their health challenges. But it’s also, as you can
imagine, difficult work that is cognitively and emotionally demanding. The
pressure of 15-20 minute visits makes things harder than they should be, but
even if we went to 30-45 minute visits, the work will remain fundamentally
intense and somewhat taxing for the provider.
Can
anyone seriously argue that we won’t need PCPs to do the work above for
Medicare beneficiaries over the next 20 years? (Plus we’ll need them do manage
dementia, falls, and all the other geriatric problems too.)
Ok.
Then if we agree that the work above is essential to the wellbeing of millions
of older adults, and is a crucial component to providing overall cost-effective
healthcare to the Medicare population, we must get serious about how we can
recruit and keep clinicians as Medicare PCPs.
The benefits of a 35 hour work week
If
the work of  Medicare PCP could be
organized so that it fit into a 35 hour work week, we’d see the following
benefits:
  • More
    clinicians would be willing to do, or stay, in the job.     Let’s face
    it, we have ample evidence that work-life balance is important to the
    younger generation of physicians, especially those with young children. As
    much as this dismays the older generation of physicians, this trend seems
    to be here to stay, so perhaps we should learn to work with it. Debt relief
    – the usual hope for attracting people to primary care – is never going to
    be enough on its own.
Given
that we are asking PCPs to actively engage with patients and families, embrace
shared-decision making, adapt to technological changes, and make a whole host
of behavior
changes, making sure that clinicians in this role aren’t burnt out by long
working hours just makes sense.
Summing it up
The
impending shortage of PCPs constitutes a national emergency. In order to
provide the growing Medicare population with compassionate, effective
healthcare at a sustainable cost, seniors will need stable relationships with
PCPs who can function as their strategic medical consultants, collaborate in
helping to meet healthcare goals, and provide emotional support.
Doing
this type of PCP work can be extremely rewarding, but it’s also cognitively and
emotionally demanding.
Structuring
the job of Medicare PCPs into a 35 hour work week would probably attract more
clinicians to the job, including those with young children. It would also help PCPs maintain the cognitive and
emotional resources needed to do the job consistently well, and could reduce
burnout in this group of key clinicians.

What my home renovation taught me about practicing medicine

In
2006, as I was starting my geriatrics fellowship, we started renovating our
home.
This
took almost two years from start to finish. It was a long, arduous, expensive,
and often stressful process. And this experience ended up profoundly
influencing my philosophy as a primary care physician, and my approach to
practicing medicine.
To
this day, I’ve had minimal experiences as a primary care patient – I’m in my
mid-thirties, and am lucky to have always been pretty healthy.
But
I’ve been an inexperienced homeowner trying to muddle my way through a major home
renovation, and that, I will submit, has many interesting parallels with being
a primary care patient.
For
instance, although my life and overt health wasn’t at stake, we were investing
a lot of money – and time –  into a very
complicated undertaking in which we had no previous experience. (We ended up
entirely changing the layout of our flat, including moving the entire kitchen.)
We
had to identify professionals to work with, trust in their expertise and
ability to get the job done well, yet keep an eye on how things were going and
make sure to occasionally advocate for ourselves. And when the project would be
completed, we would be the ones living indefinitely with the consequences of
our choices and our experts’ choices.
So
when I think about physician-patient relationships, I end up thinking back to
my renovation experience, remembering our experience struggling through those
two long years. I think about how we negotiated trust and control with the
professionals involved. And I especially remember who felt helpful to us, who
didn’t, and why.
Here’s
what happened with two of the key professionals we encountered, and the lessons
I learned for practicing medicine.

Two professionals, two approaches

Now,
a renovation was a something neither my spouse nor I had experience with, and
we thought hard before deciding to go for it. But it seemed to be the best of
our options: we’d decided to renovate our flat because although it was
spacious, the layout was truly terrible and the kitchen finishings were
uninspiring to say the least. (We would’ve moved, but couldn’t find anything
else that we could afford. These were the boom years in SF real estate, so it
was cheaper to refinance our existing flat and remodel than to move and double
the mortgage.)
So
we told ourselves that our hard work and investment would result in a much
better space for living and would surely improve the overall value of our home.
We checked out some books on home renovation, and then we started looking for
help getting the project done.
The
first important decision we had to make was choosing an architect. We needed
someone to help us envision how we might change and improve our flat, and then
create the plans for a contractor to follow. In other words, the architect was
going to be the linchpin of our entire experience.
But
how to choose the right architect? None of our friends had worked with any
local architects. Somehow we found a few to interview, and ending up choosing
one who I’ll call Sam (not his real name), in part because he charged an hourly
rate rather than a percentage of the entire project.
Sam,
we realized over the next few months, was a big mistake. Although he was
capable and experienced as an architect, we repeatedly clashed over details of
the emerging design, and the experience of working with him was stressful. He
pooh-poohed our request for a pantry, since that interfered with the elegant
visual balance of his proposed kitchen design, and rolled his eyes when we
asked for a hallway door to separate the bedrooms in the back from the noisier
front part of the house.
Sam,
in other words, was more interested in realizing HIS vision for our home than
he was in helping us figure out how to create a comfortable space that met OUR
needs. He also didn’t have much patience for discussing little things, like our
making sure there were lots of electrical outlets conveniently placed.
Sound
like any professionals you know?
As
things got rockier with Sam, we started to consider the unthinkable: terminating
our relationship with him, and having someone else supervise the construction
based on Sam’s plans. This was a scary proposition to us: we didn’t like working
with Sam, but how to make sure we found someone better?
After
all, we needed SOMEONE to keep guiding us through the renovation. Despite my
doing constant research in online forums and through books, we were overwhelmed
by the complexity of the project, and I was terrified that we’d make more wrong
choices and end up with a mediocre outcome after investing so much in the
project.
Then
we took a look at our contract with Sam, and realized that although we had been
paying him for his time drawing the plans, the contract stipulated that plans
are “Instruments of Service” which remain property of the architect. In other
words, if we terminated the relationship, no plans to keep working with.
It
was, of course, a contract provided by the American Institute of Architects.
And as such, all the boilerplate heavily favored the interests of the
architect, not of the homeowner.
Luckily
for us, Sam himself proposed we terminate the relationship, and agreed to give
us the right to the plans, in exchange for our paying him for his time thus
far.
As
the strictly architectural work on the project had been completed, we opted to
replace Sam with a more affordable interior designer. This time, we were lucky
enough to find a very good person to guide us through the gazillion design
choices we still needed to make: Gale Melton.
Like
Sam, Gale charged an hourly rate, had years of experience, and had a good sense
of design.
But
unlike Sam, Gale made an effort to get to know our tastes and priorities, and
then applied her skills to help steer us towards designs that WE liked. Instead
of asking us “What do you want?” and looking impatient when we couldn’t
respond, she took time helping us discover and then articulate our preferences.
And throughout the following year, she helped us effectively process and
finalize a truly staggering number of design choices.
In
short, one expert professional performed a core part of his job but left us
stressed and frustrated. Whereas the other helped us navigate a dizzying array
of decisions and was instrumental in our creating a living space that is
comfortable, appealing, and a good fit for our needs.

Primary care physician as consultant


Would
I be the doctor I am today if I hadn’t gone through this renovation experience?
I’m not sure, especially since it took place during a formative time in my
clinical geriatrics training.
In
fact, as we were struggling with Sam in the fall of 2006, I completed two
months on the palliative care service. This was probably the most valuable and
concentrated clinical learning experience I had as a trainee, and included a
lot of teaching on communication skills. And of course, teaching on discussing
goals and adapting to people’s preferences.
These
two overlapping experiences prompted me to think long and hard about how physicians
help patients, especially in primary care.
My
conclusion was that how we practice as professionals isn’t just about having
sufficient depth of knowledge and the requisite technical skills.
It’s
also about our fundamental assumptions regarding how those skills should be
applied.
From
my renovation experience, we discovered that as homeowners we really wanted to
work with experts who:
·        
Made
an effort to understand our preferences, and helped us articulate them
·        
Educated
us so we could more effectively participate, and helped us understand likely
downstream consequences of certain choices
·        
Respected
it when we prioritized things differently from the expert
·        
Appreciated
that we had much more at stake in the project than the expert did
·        
Were
understanding when we occasionally sought an extra opinion from a third party,
or otherwise tried to double-check something
·        
Were
patient with multiple questions or attention to details
·        
Could
explain how recommendations were linked to a certain understanding of our
preferences or priorities
And
of course, we discovered that we *didn’t* want to work with experts who acted
as if they knew what was best and were annoyed when we didn’t agree.
We
also realized that we wanted to be able to switch experts, and if we ever have
to go through a renovation again, we’ll be sure to negotiate terms that allow
us to easily take our business elsewhere if we discover that an expert isn’t a
good fit for us.
So
in my own work as a primary care physician, I’ve tried to think of myself as a
consultant to the patient. My job is to serve the patient, usually by helping
him or her understand the medical situation and the options, and then working
out a feasible plan to move towards the person’s health goals.
Different
patients, of course, want different things. Some ask a lot of questions, others
don’t. Some are directive – in which case part of my job is to speak up if I
think the direction they’re taking is unlikely to lead them where they said
they wanted to go — whereas others really want direction (in which case the
clinician still needs to ask where they want to go).
Am
I as successful as I’d like to be in implementing this approach? I don’t really
know. I’ve gotten some nice feedback from patients and families over the past
several years, but ideally I’d have some more objective method of getting
feedback. (Or feedforward, as it were.)
Still,
I think this approach is overall sound, and is consistent with medicine’s
ongoing transition away from its historic paternalism, and towards approaches
that are more respectful, collaborative, engaging, empowering, and individually
tailored towards patients’ needs.
Now,
can anyone recommend a favorite tool or technology that allows providers to
quickly learn whether they are properly adapting to their patients’ needs or
not?
And
what metrics will ACOs use to encourage providers to act more like excellent
consultants? Or will ACOs even care, as long as utilization is controlled?
Fodder
for future blog posts.


Summing it up

My
approach to practicing primary care has been strongly influenced by my
experience slogging through an extensive home renovation, a process which
required my husband and I to depend on professionals for guidance and to
actually implement this major project.
We
discovered that some professionals were much more stressful to work with than
others, and found that we needed to work with those who were willing and able
to use their expertise to help us meet our goals. This meant we needed
professionals who were not only technically competent, but also had the skills
to solicit our goals and preferences, and then effectively collaborate with us.
Healthcare
is making a much-needed transition towards organizing around patients’ needs
and preferences. For me, it’s been helpful to think of my primary care role as
being a medical consultant there to help patients understand their medical
situations, and then assist them in reaching certain healthcare goals. However,
I haven’t yet identified a robust way of getting feedback on my performance.

Zen and the Art of Problem-Based EMR Design

[This post was first published on The Health Care Blog on 3/18/13]

How to effectively keep tabs on a patient’s multiple medical problems? And how to do so without losing sight of the whole person?

The first question is the one I wrote about in a recent blog post. The second was the theme of many of the responses posted on THCB and also LinkedIn.

I love this second question; it’s an issue that’s always been of interest to me. Plus it’s especially relevant in geriatrics, where we are constantly re-orienting our approach to problems based on what seems to be happening with the whole person. (Good PCPs do this too.)

And it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the unintended effect of making it harder for all clinicians to understand what the heck was going on overall with the patient.

Based on reading my post and Wachter’s post, an EMR designer asked me the following specific questions:

  • Should the entire EHR should be functionally and logically structured around problems, or would it be sufficient for a chart user interface to be presented in a problem oriented manner?
  • What are your thoughts about the possibility of such a solution becoming overly reductionist, losing the patient between the problems?

Good questions!

Should an entire EHR be organized around problems?

Or would it be sufficient for a chart user interface to be presented in a problem oriented manner?

I myself like the idea of the problem-based interface being one of several options, as I can imagine myself wanting to toggle between a chronologic list of encounters (a comfortable and familiar view for many docs) and a list of problems.

Actually, a neat visualization of a problem list can be seen here (try clicking “show all health problems” in the matrix):

This was part of Dr. Graham Walker’s proposal for last fall’s Health Design challenge, and one of the things I really liked about it was how the size of the problem icon relates to “how important” the problem is. (We could quibble about how that gets decided, but it’s still a nifty idea!) As they say, a good graphic is worth a thousand words.

To return to EMRs and the problem list: I don’t know whether an entire EMR should be organized around the problem list; I’d have to see an example of this and probably try it before I could venture an opinion.

However, I certainly want to be able to view data in EHR via a problem-based interface, and in my previous post I described how this might be possible via using problems as tags. Between tags and a robust search function – think of Gmail, or Evernote – information in an EMR could become much more findable and organizable. Which would be great for clinicians!

How to keep a problem-based approach from losing sight of the person?

Easy in principle. The key is to make sure a clinician regularly considers the patient’s overall medical picture. To use the altitude analogies that are sometimes used in business, this corresponds to the 10,000-30,000 ft view. Another way to describe it would be to make sure to consider the forest, and not just a few trees (or a long list of individual trees).

In practice, this gets tricky for the following reasons:

  • Many practicing doctors clearly are not routinely doing this.
  • The ongoing shift – driven by technology, the need to collect metrics, and the worsening time-pressures under which doctors practice — in how doctors do their charting seems to be exacerbating this. Whereas doctors used to dictate whole paragraphs, or write out chart notes, now we have EMRs that provide templates or direct us to chart by problems. I agree with Bob Wachter and others who have pointed out that these technological shortcuts probably interfere with cognitive synthesis. 
  • We have no clear professional standards – that I’m aware of – that specify how and when doctors should perform this exercise in clinical big-picture thinking. 
  • Most EMRs seem to not be designed to encourage this kind of big-picture summary thinking.

This means that among physicians, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice.

(I myself like to start with a blank piece of paper and I jot down a 1-2 sentence summary of the patient’s medical situation, along with a few issues I want to address. Then I go look for the relevant supporting data within the EMR. And I do it right before I go in the patient’s room or house, because I can’t think as well once they start talking to me. Idiosyncratic!)

But to provide good care, physicians need to toggle between a zoomed-out, big-picture view of the patient, and also a zoomed-in, tackle-a-problem-in-depth view. This means that EMRs should assist physicians in either view, and ideally would remind physicians to address both.

How EMRs could help us keep track of a patient’s overall medical picture

In his post, Dr. Wachter ends up proposing that an “Uber Assessment” field be added to each EPIC note, and that clinicians be required to enter a free text narrative summary of what is going on with the patient. This, to me, sounds like the old written attending notes of yore, which usually consisted of one concise and high-yield paragraph. (I trained at UCSF in the days of paper hospital charts; Wachter was my attending for two weeks in 2004.)

But a commentator objects, and not just any commentator: it’s Dr. Lawrence Weed himself, creator of the “problem-oriented medical record”, in partnership with his son Lincoln Weed!

If you have read Dr. Wachter’s post, but not Dr. Weed’s riposte, I strongly urge you to return to the original post here, and read Weed’s comment in its entirety. (Be sure to use tech to your advantage: search the webpage for “Lincoln Weed” and you can find it right away.)

In his lengthy and detailed comment, Dr. Weed clarifies that SOAP notes should not be conflated with POMR:

“Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.”

He goes on to object to the idea of relying on clinical synthesis being done the old-fashioned way, which is to say, via physician judgment:

“Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.”

And then, Weed completely wins me over with this paragraph:

“But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. [Emphasis mine.] When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.”

And also this one:

“Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. [Emphasis mine.] Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.”

Crucial points Weed makes that I love:

  • Electronic tools should help us quickly gather the relevant data points, and should provide much initial information processing.
    • Yes! We clinicians should not have to root around in an electronic chart, expending energy trying to find the information we need.
  • We need a good processes and tools to support clinical synthesis.
    • Given what we know about human fallibility in cognitive processing, this sounds like a terrific idea.
  • Cognitive effort should be in reviewing the output of the electronic processing, and in discussing with the patient. 
    • Being able to explain something to a patient in plain English is a great test of how well one understands things overall, and offers patients the opportunity to ask questions and participate in making a plan. Love it.
  • Assessment should be about setting priorities.
    • Yes yes yes! Especially in complex older adults, it’s easy for both clinician and patient to become overwhelmed by the sheer number of problems on the list. A joint effort identifying the top priorities serves all parties well.
  • Planning, execution, and feedback are important. 
    • This speaks to my concerns about letting things fall through the cracks. We need support in fully fleshing out how we will address a certain problem, in executing the plan, and in following up on how it’s going. Task/project management software could be adapted and used within a collaborative EMR to help with this.
  • Patient involvement is essential. 
    • Weed’s approach advocates for communication and collaboration with patients, both to set goals regarding plans for each problem, and to set priorities and work out an overall plan. Hear hear!

Discovering Weed’s historical contributions and recent views on medical charting was a very welcome perk of following up on my problem list post. He published a book in 2011, titled “Medicine in Denial.”

Has anyone read it? I’m wondering if Dr. Weed is involved in any ongoing EMR development efforts.

Summing it up

To do their work, clinicians need to address medical problems in depth and keep track of a potentially long list of problems, all while not losing sight of the patient as a person. This has always been challenging in medicine and is becoming more difficult due to information-overload and current trends in EMR charting. (Dr. Bob Wachter’s 2012 post on using EPIC to chart at UCSF hospital highlights some of these issues.)

A robust problem-oriented view within EMRs would be very helpful to primary care clinicians, and I would love to see problems used as tags within other aspects of the EMR. However, this problem-view would have to be implemented thoughtfully, in order to not hamper the clinician’s process for considering the patient’s overall medical picture.

Currently, when and how to consider the patient’s overall big picture medically remains a very individual and idiosyncratic practice, both in the hospital and in the outpatient setting. In the comments to Dr. Wachter’s post, the legendary Dr. Lawrence Weed details a number of ways in which technology could make this synthesis process more manageable (by helping to collect relevant data) and more structured for clinicians.

Dr. Weed also earns my undying admiration as he calls for clinicians to collaborate with patients in setting goals for problems, and in setting priorities, and in implementing a plan. It would certainly be interesting to try to implement some of Dr. Weed’s recommendations via EMR.