GeriTech

In Search of Technology that Improves Geriatric Care

primary care

When multiple problems lead to multiple recommendations; how to help patients succeed?

How to help patients and caregivers keep track of and follow through on the many things we ask them to do?

I found myself thinking about this yet again last week, after the group of UCSF students I was teaching brought up the following concern:

“We’re worried about the patient getting overwhelmed by our making too many recommendations.”

Good point, learners.

I had to admit to them that I probably don’t think of this nearly as often as I should. But it’s such a good thing to consider. Because the truth is, I think it’s often harder than we realize for patients and caregivers to keep up with the plan for the many problems on an older adult’s list. (It can also be tricky for a clinician to not lose track of everything going on — a topic for future posts.)

In geriatrics, of course, we usually have a lot of problems to address: six or more in a visit isn’t uncommon in my practice. That’s because frail older patients have many ongoing chronic conditions, and often raise additional complaints at each visit.

But even younger Medicare patients often present with multiple problems.


Here’s a common scenario: If you have diabetes, high blood pressure, arthritis, glaucoma, are on eleven medications, and in the visit we uncover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation, then we are going to have a lot of shared decisions to make. Which will lead to a long list of recommendations.

Furthermore, I consider difficulty managing meds to be a sign of possible
cognitive impairment or possible financial difficulty; if either or both
are present, then plans for every other medical problem will need modifying.

(Also note that this isn’t a very medically complex patient in geriatrics; many present with this stock set of problems plus congestive heart failure, COPD, kidney disease, and complaining of pain and shortness of breath too. Oh and, rash and toe fungus. )

So here we are now with our mutually-agreed upon problem list and care plan. Now what?

The challenge for patient and caregivers: so much to do

My own experience has been that most patients and families have trouble keeping up with more than 1-2 recommendations. The trouble is, for adults with multiple medical problems, a single visit can generate multiple recommendations. And of course, the more action a recommendation requires, the less likely it will happen.

The simplest recommendations ask patients to do something simple, just once. Like “Stop medication X.”

But most recommendations are more complicated: “Increase your metformin to 500mg three times daily” requires a small ongoing change in what a person does every day.

Then there’s “Talk to your daughter about helping you figure out a way to not forget to take your medications.” (This is the kind of amorphous directive that the Heath brothers warn about in Switch, one of my fav books on change management.)

Or, “Check your blood sugar every morning before eating. If your blood sugar is over 150 for three days in a row, increase your Lantus by 2 units.”

Or “Start bladder training. You can review the attached handout for instructions.”

Let’s reconsider the example of the patient above, with her out of control blood sugar and blood pressure, plus falls, anxiety, urinary frequency, difficulty managing medications, and social isolation. Here are the problems we routinely face in helping such patients:

  • Do we list recommendations for all the problems we uncovered in the visit, or just for a few?
  • For every problem we make recommendations for, how to help patients and caregivers follow through?
  • If we focus one just one or two problems, how do we ensure we don’t lose
    track of the other issues? (Patients seem to hate coming back every
    week for another visit, but that’s often what we suggest, assuming we
    have appointment slots available.)
  • How do we clinicians update the plan for a problem, based on feedback we get from patient and family? (Many problems require a trial of an intervention before we can decide how to proceed long-term, or may require diagnostic results before we move on.)

What kind of technology can help us?

 
Technology is already helping, in that EHR systems are now creating clinical summaries for patients (it’s a criteria for Stage 1 Meaningful use).

This is a step in the right direction, but it’s not enough.

What patients and caregivers (and the clinicians helping them) really need is something more on the order of a sophisticated task management system. Or possibly even project management tools.

Specifically, we need something that:

  • Can keep track of multiple problems and recommendations
  • Helps patient and clinicians identify which recommendations will be the focus now, versus later
  • Allows us to update each other on the status of problems, and the plan for each problem
  • Allows us to break down the plan for a given problem into manageable and actionable chunks
  • Allows us to share information as needed with others involved in addressing a problem, i.e. other clinicians (such as nurses for problem-specific coaching), family caregivers, etc.

A bonus in my view would be technology that allows the clinician to enter several recommendations all at once (when the clinician is thinking comprehensively about the patient), but allows patient and caregiver to work through them over time.

So for instance, let’s imagine that for the patient above I have recommendations for the following problems:

  • diabetes management
  • blood pressure management
  • urinary urgency
  • falls
  • anxiety
  • medication management
  • socializing

Let’s also assume that the recommendations for these problems are NOT interdependent (often they are, but we’ll go for a simpler scenario).

I’ve actually discussed and provided management recommendations to patients and families on this many problems within a single 30 minute visit (it’s a bit of a hustle, but possible).  But asking the patient to take action for each problem would probably be overwhelming.

However, imagine a platform in which I propose recommendations for all problems and prioritize them. On the patient’s side of the technology, he or she gets to work through a problem for a period of time, and then later is given recommendations for the next problem. (These could be staggered based on time, such as weekly, or based on completion of the previous problem’s plan.)

Such technology could allow us as clinicians to be more comprehensive, with less risk of overwhelming patients and families. This would enable clinicians to make best use of their time, and help patients be more successful in taking the many steps needed to improve their health.

So is this technology out there? I’m not sure. Several companies are working on consumer products meant to help caregivers manage multiple tasks, but it’s not yet clear to me how easy it will be to integrate clinical recommendations into the programs.

On the provider side, patient portals are becoming de rigueur, but as far as I know, they have not yet evolved to support this kind of sophisticated care plan management for patients.

But hopefully that will change. In the meantime, if anyone has come across technology that helps clinicians help patients manage multiple problems, I’d love to hear about it.

In a nutshell

It’s very common for older adults to present to a primary care clinician with multiple problems, which can generate multiple recommendations for patients and caregivers to implement at home. But patients often have difficulty managing more than 1-2 recommendations, so a comprehensive approach is often too overwhelming.

We need technology to help patients follow through when there is a lot to do. Specifically, we need help making multiple recommendations more manageable for patients and families. Something along the lines of sophisticated task management (or perhaps project management?) would help.

The ideal technology would facilitate and reinforce effective collaboration between clinicians, patients, and caregivers, and would allow all to work through a longer problem list together over time.

If you can suggest any such technologies that might work for older adults with multiple problems, definitely let me know.

Care coordination dinosaur still lumbering and STILL don’t have the info requested

Wow. I knew it could often be a pain to get medical records from another doc, but until recently, I hadn’t appreciated just how convoluted the process could be. (That’s because until recently, I practice in conventional office settings, where getting records was a task delegated to other staff members. But now I’m trying the micropractice model so doing it all myself, which is instructive.)

For those interested in coordination of care (or wondering why their PCP never seems to know what the other doctors did), let me update you on the latest twist in my quest to get information from the orthopedic surgeon.

A few weeks ago I received the snail mail letter, informing me that I had to submit my request for the surgeon’s notes to the hospital with which he is apparently affiliated. So I faxed the request on 11/15/12, including a release of information signed by the patient’s DPOA.

Today I finally get a fax back.

No records included.

Instead, I’m informed that the request can’t be completed because it’s missing DOB. They fax me part of my own fax. It does happen to include the patient’s DOB at the top (my EHR automatically inserts along with patient’s name), but I guess somehow they missed that part.

They also include their own release of information form, which has to be signed by the patient.

Grrr.

I call the medical records office. I speak to a very nice person who knows nothing about the fax I got earlier, but advises me to fax my request and signed release of information form again. He does promise he’ll try to take care of it soon, but warns me that though he’ll be able to provide the discharge summary I requested, it will take longer to get the surgeon’s initial consultation. That’s because he’ll have to request those from the surgeon’s office (you know, the one I contacted in the first place), and it can take a while to hear back from them.

Oh and, I discover that a second copy of their fax has arrived in my fax inbox. This version includes a page about an entirely different patient. So much for the current system protecting one’s confidentiality.

So, more waiting for the information. I haven’t felt that it’s critical to the work I’m doing right now on the case, but I’d like to see it just because I like to have checked everything.

In a nutshell:

It can be incredibly slow and aggravating to try to get medical records from another doctor. (No wonder support staff in medical offices often look so stressed out.) The current paper-and-fax based system is also fraught with potential for error, such as faxing the wrong patient’s information to who-knows-where.

I can’t wait for the day when the new dawn of healthcare technology makes these kinds of problems a quaint story from the past.

How the new brain scan for Alzheimer’s could help, and won’t help

There’s
a powerful new Alzheimer’s diagnostic test (the new brain scan) on the block, and now we’re all
going to have to decide if we want to use it or not. (My colleagues at GeriPal.org seem generally skeptical.)
This
is an especially relevant question for a outpatient geriatrician like me: I’m
often confronted with the complaint of memory problems, I do a fair amount of
diagnosing dementia (usually on my own, with the occasional referral to a
memory clinic or neurologist), and I do a lot of counseling of patients and
families, usually over the span of months to years.
In
other words, I field memory complaints and dementia diagnosis as they appear in
the primary care clinic, and with the aging population surging into Medicare, I
essentially do what front-line generalists will need to do for millions of
elders over the next 10-20 years.
So
would I order this scan, for someone with memory problems? How would this help
or hinder me, and the families I’m trying to help? What kinds of benefits and
harms will we get for the extra cost of this test, given that there is
currently no cure for Alzheimer’s and not even any reliable ways to slow the
progress of this devastating disease?
A  recent NY Times article highlights these questions, and features some of the first private patients to have the new
scan. It’s a good story, and if you haven’t read it yet, you should.
But
it’s the story of trying to confirm the presence or absence of Alzheimer’s
disease.
Whereas
in my world, the story is about how to help people with memory impairment. Which
is not quite the same story, and involves slightly different questions. In
particular, I don’t just think “Is it or is it not Alzheimer’s?” What I think
about is:
  • Is this
    dementia?
    With patients, I usually explain that dementia means developing permanent
    brain changes that make memory and thinking skills worse, to the point
    that daily life skills are affected. I then explain that Alzheimer’s is
    the most common underlying cause of permanent brain changes. 

  • Is anything
    making this person’s cognition worse than it would otherwise be?     It’s
    especially common to find that medications (such as benzodiazepines for sleep) are making older people worse. Several other medical conditions
    (i.e. hypothyroidism, depression) can worsen cognition and should be
    checked for as well.

  • Any special
    neurological features that I should make note of?     I briefly
    check for signs of parkinsonism, hallucinations (common in Lewy-Body
    dementia), or neurological changes suggestive of subtle strokes. But
    otherwise I don’t spend too much time trying to pin down the underlying
    dementia, unless something strikes me as distinctly odd. Overall, I find
    the principles of helping patients and families with dementia are
    basically the same for the most likely causes of dementia (Alzheimer’s,
    Lewy-Body dementia, vascular dementia).
The
patient and family, of course, have their own questions and concerns. They
certainly do often ask if it’s Alzheimer’s. But we shouldn’t answer that
question too narrowly. Many people don’t understand the difference between
Alzheimer’s and dementia (I’ve had people tell me “Thank God it’s notAlzheimer’s” when I broke the news of likely dementia). But overall, what scares
them is the specter of progressive cognitive disability.
Most
of all, in my experience patients and families want to know:

  • What
    is going on?
  • What
    should we expect for the future? 
  • Will
    this get worse? How fast?
  • What
    kind of help is there? Are there treatments?
  • How
    will we manage?

Back
to the article. What would’ve happened to those patients if they hadn’t had the
scan? And what is still left undone or unresolved after the scan?
Consider
Awilda Jimenez, the woman featured at the start of the Times story, who becomes
forgetful at age 61. Here’s how things usually unfold when I see someone like
her:
  1. I make a preliminary assessment of cognitive
    abilities.     I use a combination of office-based cognitive test, like the
    Montreal Cognitive Assessment, and asking about function, especially IADLs like finance and driving. The article doesn’t say how Ms. Jimenez scored
    on these (one hopes they were checked before offering her the scan), but
    it’s not uncommon for someone with early Alzheimer’s to score 24 on the
    MOCA and have problems with memory and finances.
  2. I also look for exacerbating factors, like
    medication side-effects, or other illnesses.     Let’s assume I find none.
    Let’s also assume the neuro exam is generally benign (other than the
    thinking problems).
  3. I then explain to the patient and family that
    there does seem to be evidence of problems with memory and thinking.     If
    the problems are fairly prominent, we start to discuss the diagnosis of
    mild dementia, and that it’s probably Alzheimer’s. If the problems are
    subtle and things feel inconclusive to me, or if the family wants more
    evaluation, we talk about referring for neuropsychological testing, to get
    further insight into the cognitive problems.
    • Let’s say the neuropsychological testing comes
      back indicating deficits; a common conclusion is that the findings “may
      be consistent with an early dementia such as Alzheimer’s.” Then I get to explain to
      patient and family that it’s probably dementia, probably Alzheimer’s,
      could be vascular or another, generally slowly gets worse but occasionally
      seems to stop
  4. Let’s see how this evolves. I almost always end up telling families that we will need to see what
    happens over the next 6-12 months. 
  5. Practical strategies for right now. I coach families on avoiding
    psychoactive medications and other common causes of delirium. I also encourage them to look for dementia support groups, and try to point them towards resources for learning more about living with dementia.
In
other words, as things currently stand, evaluating memory impairment in someone
who’s early in the dementia process often ends up with our telling patients
that they probably have something bad: mild dementia, most likely Alzheimer’s.
This
uncertainty is frustrating for clinician and patient. (It’s even worse when the
deficits are in the range of mild cognitive impairment, or in that “is this
affecting daily function?” gray area.) So it seems that the new brain scan
should be a boon, with its ability to give a definite yay or nay on whether
Alzheimer’s is present.
Today,
patients and families can cling to the hope that maybe it’s not Alzheimer’s,
maybe it won’t keep getting worse, maybe it’s something else. I have seen
patients and families resolutely set aside the possibility of Alzheimer’s (why
dwell on the possibility of something horrible coming into your life), and
other families obsess over the issue for months. 
Regardless of which approach
they take, in most cases, the cognition keeps getting slowly worse, and 1-2
years later the family is enmeshed in caring for someone who has become quite
cognitively disabled. At that point, they are trying to survive and we clinicians
are trying to help them maintain the best quality of life possible.
Back
to the new scan. I would briefly summarize the benefits and burdens as follows
(for patients in the mild/early stage of symptoms): 
Benefits:
  • Reduces period of clinical uncertainty for
    those patients who in fact have Alzheimer’s.
    • With a positive scan, families could more quickly move into grieving, acceptance, and hopefully planning for the
      upcoming challenges. (Engagement!)
    • Although there is no cure and drugs don’t
      tend to delay progression very much, clinicians can and should focus on the many ways to optimize
      the person’s function. Caregivers can focus on getting from coaching and support.
      Other clinicians should be alerted to the diagnosis and modify their work
      accordingly.
    • A negative scan in someone with
      symptoms would presumably spur a search for the real problem.
Burdens:
  • Takes a fair bite out of the payor’s wallet.
    Currently the scan is paid for out of pocket.
What the scan doesn’t do:
  • Offer an explanation for cognitive impairment
    in those patients who don’t have Alzheimer’s.
  • Identify co-existing vascular disease or other
    cause of progressive dementia.
  • Identify and modify factors worsening
    cognition, like medication side-effects or other illnesses.
  • Tell patients how quickly their dementia will
    progress, and what kind of help they will need in a year. The progression
    of Alzheimer’s is highly variable from individual to individual.
  • Provide dementia education and support to family
    caregivers.
In
short, whether we’ll benefit from the scan really depends on how much families
and clinicians benefit from eliminating that period of uncertainty, as well as
on our ability to provide good dementia evaluation, management, and support to
patients and families. 
Unfortunately
most dementia patients currently get sub-optimal medical care, and their
caregivers get inadequate coaching and support. 
If the scan helps bring people to the resources they need earlier, and
more effectively, I’ll be for it. But if it turns yet another radiologic money
suck and everything else continues as usual, I’ll be disappointed.

In a nutshell:

The pragmatic outpatient evaluation of someone with memory complaints involves much more than answering the question of whether or not there is Alzheimer’s pathology in the brain. 

However, using the new scan to get an answer to that question sooner rather than later could eliminate a lot of the uncertainty and watchful waiting that families and clinicians currently experience. 

If (and this is a big if) this helps patients and families access better dementia care sooner, the brain scans could be quite beneficial.

[Interested in Alzheimer’s diagnosis? Here’s a related post: Four things people with possible Alzheimer’s really need.]

Drive: The Surprising Truth About What Motivates Doctors to Provide Better Care to Elders?

I’ve recently started reading Daniel Pink’s Drive, and it makes me repeatedly want to jump up and down shouting “Yes! Exactly!”

It also leaves me repeatedly thinking this:

Everyone pushing for better primary care for elders should read (or reread) this book.

As in:

  • Accountable Care Organizations, the great shining hope for healthcare improvement, who will want better care for elders in order to reduce their financial risk (a rather sordid reason to improve care, but there it is).
  • Quality champions, who are trying to figure out how to rejigger systems so that clinicians do better. (Teach them to work in teams!)
  • Policy wonks, who are very into incentivizing providers these days. (Pay clinicians an extra $10 per member per month! That’ll do the trick!)
  • Healthcare entrepreneurs, many of whom seem to believe that primary care clinicians will be shelling out for their innovations in order to compete more effectively in meeting the demands of empowered and engaged consumers. (Hello? Have you heard of the primary care provider shortage in Massachusetts?)
  • Concerned patients and caregivers, who are certainly right to demand better care, and will need engaged and motivated clinicians with whom to forge fruitful collaborations. (Your doctor is probably not going to feel like being more helpful to you because she gets dinged by her ACO when the quality metrics don’t pan out).

For those who haven’t read Drive or aren’t familiar with the basic premise, this is a book that summarizes a recent evolution in how psychologists understand what motivates individuals.

Basically, people used to think that individuals were motivated by essential biological drives (survival, procreation, etc) and then also by rationally responding to extrinsic factors such as rewards (i.e. money) and avoidance of punishments (i.e. fines).

However, psychologists eventually noticed that people often engaged in behaviors for which there was no obvious benefit, other than the enjoyment of engaging in the activity. And in some cases, this activity led to very significant, important products, such as Linux (open-source software) and Wikipedia.

This third drive has been called intrinsic motivation. My guess is that if you are reading this post, you’ve probably already heard about this drive, and maybe even come across some of the literature that suggests that in physicians (a group in which many start with high intrinsic motivation to do their work), use of external motivators may damage intrinsic drive (see here & here).

So my question to all is, if we know about this third drive, then why are most of the suggestions for improving primary care (which should be the foundation of good care for frail elders) rooted in manipulating extrinsic motivators?

Here’s a quote from Pink:

[Organizations] continue to pursue practices such as short-term incentive plans and pay-for-performance schemes in the face of mounting evidence that such measures usually don’t work and often do harm.

Pink goes on to define work as algorithmic (follow a set of instructions) versus heuristic (experiment with possibilities and devise a novel solution). 

Which do you think requires more intrinsic motivation? That’s right, heuristic work.

And does providing comprehensive, compassionate, collaborative care with a medically complex patient and his or her family sound like an algorithmic task to you, or a heuristic one?

This to me, is a no-brainer. Obviously there is much medical care that can and should be done by algorithms.

But not all medical care can be done algorithmically, especially when patients are elderly, complex, embedded in a care circle, and require personalized care and shared decision-making. 

To have quality medical care for elders, primary care providers should be doing complex collaborative problem solving with the patient and family.

That’s heuristic work. That requires intrinsic motivation.

So every time you come across some system, tool, or technique for improving primary care, I suggest you ask yourself:

“How can we use this is a way that improves the clinician’s intrinsic motivation, or at least doesn’t snuff it down too much?”

We should also be talking about how to bolster and support clinicians’ intrinsic motivation to work effectively with patients. Remember, over 50% burnout in front-line clinicians in a recent survey. Unless you truly believe it’s possible to have quality primary care for elders without engaged clinicians, something must be done.

Speaking of what should be done, Cassel and Jain published a Viewpoint in JAMA this past summer which addresses some of the above:

Those advancing physician-level interventions are looking to change how physicians do their jobs. A more global approach—in keeping with more attention to intrinsic motivation—would be to change how physicians perceive their job. Physicians who are satisfied with their work lives provide better care….To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity. Rewards should reinforce, not undermine, intrinsic motivation to pursue needed improvement in health system quality.

Ok. I’m going to be thinking about intrinsic motivation as I think about implementing tech and systems to improve geriatric care.

Btw, yours truly is writing this blog on her own time, for no money. Intrinsically motivated 🙂

Micropractices, IMPS, and Improving Primary Care

This past weekend I attended my first IMP Camp. IMP originally stood for Ideal Micro Practice, but now stands for Ideal Medical Practice.

I went because after years of being an ardent supporter of team-based primary care, I decided last spring to switch to practicing geriatrics in a solo micropractice.

This is a career development which I still consider with mild surprise. I was after all (and continue to be) a huge fan of Tom Bodenheimer’s work proposing that primary care should be delivered by high-functioning teams, rather than by overwhelmed clinicians trying to do everything themselves.

However, finding a high-functioning team to join is not so easy. Part of the problem is the still-predominating fee-for-service payment system, which generally doesn’t reimburse medical work that isn’t provided face-to-face and by a “billable provider” (i.e. physicians, NPs, PAs, but not RNs). This can really cripple outpatient geriatric care, which I believe ideally would involve plenty of phone follow-up, care coordination, and nurse-led coaching interventions.

Of course we now have a move towards accountable care organizations (ACOs) and value-based payments, but it’s not yet clear how this trend will mean for the experience of the average on-the-ground primary care clinician. (Will ACOs be yet another stakeholder complaining about what we didn’t do? Or will they lead to substantive support in helping us do our work well?)

Furthermore, even when funding mechanisms support a team-approach to primary care, one still needs the team to be high-functioning. As most people who’ve worked on teams can tell you, not all teams work well. This is especially true in primary care, where healthcare providers may be asked to take on very different roles without getting adequate coaching and support in making the requested changes. (To his credit, Bodenheimer is well aware of the rhetoric-reality gap when it comes to teamwork.)

What’s a clinician to do when she wants to provide high quality outpatient care but is worn out by primary care as usual?

My answer — for now — is to try an independent micropractice. The micropractice is the brainchild of Dr. Gordon Moore, a family medicine doc who realized that by leveraging technology to strip his practice setting down to a minimum of staff (as in, none) and overhead, he could practice better primary care. Better, as in, his patients were happier and he was happier. In particular, Moore found that this model:

  • Improved access, leading to better care and better patient satisfaction. Being the only one answering the phone means a clinician can respond quickly to patient requests, and is always in the loop.
  • Allowed more attention to direct patient care. A small lean practice requires less management and coordination, especially when technology is effectively leveraged to handle administrative work.
  • Facilitated longer patient visits. The average primary care practice spends 50% of revenue to cover overhead. Less overhead means less need to pack in revenue-generating visits every day, which means a clinician can earn a decent salary while giving patients longer visits (often resulting in higher patient satisfaction, provider satisfaction, and better care).

This last point, however, is what makes many primary care wonks nervous. Longer visits may mean happier patients, but if a clinician can make a living caring for a smaller patient panel, many start to worry about exacerbating the looming shortage of primary care providers.

Still, the micropractice model in many cases has led to macrosatisfaction for patients and physicians, and that is no trivial thing.

In fact, in listening to Gordon present this past weekend on the key tenets of Ideal Medical Practices (he has very sensibly broadened the IMP term and focuses on what constitutes ideal outpatient medical care, rather than on micropractices per se), I was struck by how well the IMP concepts dovetail with what I hear patient/consumer advocates saying they want.

What I see patients/consumers clamoring for, and how the IMP model meets the need:

  • Access: they want to be able to reach their healthcare provider promptly, as needed.
    • IMPs offer excellent phone access and usually open access scheduling.
  • Relationship: they want to feel that the healthcare provider knows and understands them, and they want to be able to work with a compatible provider repeatedly.
    • IMPs prioritize the patient-physician relationship; in small IMPs almost all patient needs are met by the patient’s usual provider.
  • Patient/consumer centered care: they want the healthcare to be organized around their priorities, and not just what the provider, or healthcare system, thinks should be the priorities.
    • IMPs emphasize care that is driven by the patient’s needs, goals and values. Many use the “How’s Your Health?” online questionnaire to regularly provide clinician’s with the patient’s self-assessment of health and needs.
  • Technology: they want healthcare providers to communicate via email and other new technologies, and to keep up with emerging technologies that might improve health and care coordination.
    • Virtually all IMPs use technology to maintain a high-efficiency/low-overhead practice. Most IMP providers are available to patients through some form of messaging.
  • Coordination: they want their primary healthcare provider to communicate, connect, and coordinate with other providers. 
    • Technology often facilitates this.
  • Support in self-management: they want providers to help them feel empowered and confident in their ability to self-manage their health.
    • By leveraging a collaborative relationship, a focus on patient-centered care, and technology, IMPs are generally able to successfully address this need.

In short, IMPS generally offer a smaller intimate practice setting which is well-suited to providing the close and collaborative patient-physician relationship that historically has been the foundation of good primary care. Just as many of us enjoy patronizing smaller local businesses, especially if we get to know the owners, patients often enjoy a smaller independently owned practice.

So if patient engagement really is the “blockbuster drug of the century,” as David Chase proclaimed in Forbes magazine last month, then IMP practices should certainly be on the radar of those looking for high-quality primary care.

What about team-based patient-centered medical homes? Well, those are a good concept too, but transforming practices may take some time. (You can read about lessons learned from the National Demonstration Project here.)

In the meantime, yours truly is trying out the micropractice/IMP model for herself, and will keep you posted on how it goes. Fortunately for me, the IMP community is largely focused on providing practical assistance to other clinicians trying to start or maintain IMP practices, so I’ve been getting some much appreciated support and advice. ((Disclosure: the IMPs have formed a nonprofit group, and I paid to become a member last April, which gives me access to some members-only informational resources.) I’d certainly heartily endorse this creative and spunky group to other clinicians contemplating a similar practice shift. Thanks IMPs!

 
Me with Dr. Anna Maria Izquierdo-Porrera, a geriatrician with an amazing practice in Maryland (www.care4yourhealth.org)
Dr. L. Gordon Moore, who is now doing really fascinating work for Treo Solutions (negotiating improved payment models with big payors). Who wouldn’t listen to a man in tie-dye?