Clinical Integration – The Essence

The term is becoming increasingly popular, much like Population Health a year ago (http://www.drrobschreiner.com/care-delivery/population-health-the-imprecision-of-language/). Journalists are hearing Clinical Integration is necessary for healthcare systems to be successful in value-based payment models (e.g., bundled payments for surgical procedures, Medicare Shared Savings Program for FFS Medicare, or global prepayment in Medicare Advantage). So the next several posts will address various aspects of Clinical Integration.

First, let’s clarify the difference between two similar terms:


Zdenko Zivkovic / Foter / CC BY

Clinical Integration (CI) refers to how geographically separate hospitals, physicians and other healthcare personnel contemporaneously coordinate with each other their separate healthcare activities for the benefit of an individual patient or a cohort of patients.  For example, a middle aged man with acute onset LLQ abdominal pain, fever and constipation is seen by 3 physicians (PCP, Radiologist and General Surgeon) in two locations (rather than three) within a 6 hour period of time (rather than 6 days) that results in a single-stage colon surgery for acute diverticulitis (rather than a two-stage colectomy and colostomy complicated by perforation, sepsis and ICU resuscitation resulting from a 6 day evaluation in a fractionated care system).

Clinically Integrated Network (CIN) refers to financially separate healthcare providers (e.g., hospitals, surgical centers, physician groups, home health agencies) that form a shared legal entity that enables single-source contracting with payors, yet is protected from anti-trust prosecution, in accordance with the 1996 DOJ / FTC rule governing CINs.  The stated purpose of CINs is to facilitate Clinical Integration (CINs do NOT create CI, at best they facilitate its creation). In practice, many just raise local market prices without achieving significant improvement in clinical outcomes (several articles to read for additional information, but here’s something recent http://khn.org/news/medical-prices-higher-in-areas-where-large-doctor-groups-dominate-study-finds/).

The best litmus test for whether true Clinical Integration is being advanced in a particular conversation is to ask this one question: ‘Will the contemplated operational, informational or cultural change reduce the duration of time that elapses between onset of illness (in the case above, acute diverticulitis) and definitive resolution (in the case above, a curative operation)?’  That’s how value is generated for the patient (avoidance of sepsis, intubation and rehab) and delivery system (lower total cost of care, higher brand).

Population Health – the (im)precision of language

hospitalNo phrase has less meaning in our industry right now than “Population Health” – this coming from the guy leading his firm’s practice in … wait for it … Population Health.

Everyone has a different picture in their head when those two words leave their mouth, yet that is the industry-standard term nowadays to convey “what comes after fee-for-service (FFS)”.  Here are merely the Top Ten most common meanings in the industry when those words are spoken:

10. Telephoning patients for the purpose of convincing them to consume preventive services

9. Disease Registries embedded in an EMR

8. Convince patients to modify their personal choices (usually via financial-pain or -pleasure)

7. Financial Bonuses to physicians for achieving a numerical score on quality metrics or for following a more complex coding and documentation process

6. Binding together physician practices for the purpose of negotiating higher professional fees (CIN)

5. A software bridge allowing a modicum of data-transfer between different EMRs

4. Buying or building more bricks and mortar to capture more patient care (revenue)

3. Convince patients to undergo biometric testing (patient engagement anyone?)

2. Enforcing the use of Evidence-Based-Protocols for common disease states

1. Providers assuming financial risk or gain for the cost of care provided

Those snapshots represent a small number of available tactics at best, and entirely miss the true meaning of Pop Health at most.  Here’s my definition of Population Health – “the manner in which healthcare design necessarily changes, once it is no longer paid for by piece.”

If the healthcare in question uses FFS as the mechanism for payment, by definition it AIN’T Population Health. The purpose of Population Health is to create higher quality care at lower or similar cost (better care experience, less harm, and more reliably favorable outcomes). In my experience, those better outcomes rarely occur and are never sustained over time, if paid for by FFS, particularly in the absence of group physician practice.

In order for care redesign to be funded and implemented by hospitals and physicians, those providers must be paid for what doesn’t happen: the ER visit avoided because the doc stayed late in the office to diagnose and treat the patient’s UTI; the cardiac cath avoided in the 22 year old with a pulled pectoralis muscle because a history and exam pays the same as cath; an admission avoided because the ambulatory physician did a great job of organizing the patient’s care, such that decompensation never occurred.  Spending time with patients, thinking about them and with them, and coordinating their care all take time, and as we all know, time is money. FFS can only account for what does happen (the ER visit, the admission, the cardiac cath); it’s non sequitur in the context of Population Health.

So the next time you hear the phrase Population Health, ask two questions: (1) “What the hell do you mean by that?”, and (2) “Before we go on, do we agree FFS payment of any type is NOT involved?”

Seeking Snake Oil

snake oil capsule“Tens of thousands of Americans undergo unnecessary surgeries that maim, and even kill, patients”.  That’s the subtitle on USA Today’s A1 article from Friday, June 21, entitled “Under the knife ‘for nothing‘.”  And the article doesn’t even address the unnecessary tests that lead to those surgeries, which harm even more patients (unnecessary testing often “discovers” normal or benign findings, leading to unnecessary intervention, causing unintended outcomes in some patients, not to mention needless anxiety and time away from work or family).  Such is our addiction to MORE in the American healthcare industry, amped up on a compensation system (fee-for-service, FFS) that financially rewards doctors, hospitals, pharmaceutical and device companies for pushing the snake oil. Let’s move some smack … Baby needs a new pair of shoes (or a longer car).

one word that can save your life, Time cover

This is not new news. Many institutions and individuals have published research asserting and confirming America’s addiction to medical and surgical overtreatment (defined here as any ordered test or performed treatment that had a poor chance of helping the patient and that physicians practicing without conflicts of interest (FFS) would not have ordered or performed). USA Today is merely the latest media source to (finally!) report on the overtreatment phenomenon in the US (Time, Newsweek, The New Yorker, The New York Times, Consumer Reports, Wall Street Journal are others). I’ve even written about it …

what would it take to convince America

The USA Today article goes on to list eight (8) common surgical procedures often done without true medical necessity. Articles within the last month have also called out tests that appear to have little to no benefit in typical circumstances: annual bimanual pelvic exam and PAP smear (New York Times online 29April2013); annual PSA testing for many men (cancer.gov and consumerreports.org ); excessive x-ray testing in many forms (medicalnewstoday.com ).

radiation - homer simpson

I’ve discussed in previous posts what drives doctors (consciously or unconsciously) to order unnecessary testing and treatments (FFS and/or absence of EBM in their practice). But sometimes it’s not the doctor who’s pushing the snake oil, rather the patient seeking it. Why? What characteristic of the human condition or American culture drives patients to seek care unlikely to be helpful, particularly when that care can harm?

I believe two forces are at play:

possibility v probability - gambling

(1) Most Americans have a poor understanding of probability; the possibility the treatment might help overshadows the probability it won’t, not to mention the possibility it might harm. A more sensible approach would be to insist upon research evidence of benefit before risking harm.  Or adhering to the approved and licensed uses for the treatments, rather than doctors and patients inventing such uses on a hunch.  For more information, see my prior post, “Our Problem with Science“, or “The Ongoing Debate for EBM: fighting for the scientific soul of our profession“.

selling hope

(2) We wish to buy hope from our doctor, rather than solely receive cognitive or surgical expertise, and who can blame us? Hope is a defining characteristic of the Human Condition.  It’s why we buy lottery tickets by the millions each month. In some clinical circumstances, however, physicians must help patients shift their mindset from “more healthcare means more hope” to “precise healthcare means best outcome”.  Hope is not a plan. By the way, many heart failure patients live longer and better once enrolled in Palliative Care rather than Intensive Care.

selling hope - cancer tx centers

What’s to be done about the supply and demand for snake oil?  One big step forward is the Choosing Wisely campaign sponsored by one of the nation’s most respected professional societies, in which we help patients choose care that is evidence-based, not duplicative, truly necessary and unlikely to harm. Tell me what else we docs can do to help our patients stop seeking snake oil … leave a comment.

Happy Doc = Happy Patient

As a patient, it’s in your interest to be cared for by a physician fully satisfied in his/her practice.  Happy docs achieve higher quality scores, provide better customer service to their patients, and concentrate harder on the task at hand – perhaps your surgery!  This relationship between professional happiness and customer outcome has been described in many industries.

doctor patient relationship

So you might wish to know what attributes of a physician’s practice to look for.  In the current issue of The Annals of Family Medicine, researchers from Boston, Iowa and San Francisco answer that question for adult primary care practices (Sinsky CA, Wilard-Grace R, et al.  In Search of Joy in Practice.  Ann Fam Med 2013;11:272-278).  Their findings of the five (5) critical components of a highly fulfilling practice are no surprise to our physicians:

#1 ProActive Planned Care:  Our population-care nurses and care managers reach patients in need of preventive screening or attention to their chronic conditions.  Our physicians order lab testing be done in the days prior to the patient’s visit, empowering shared decision-making in the exam room, highly satisfying for both patient and physician.

#2 Sharing Clinical Care Among a Team:  Our Permanente Practice employs ProActive Office Encounter (POE), a collaborative nursing process of ensuring all patient needs will be met and care-gaps closed during today’s visit.  All team members (MA, LPN, RN, Behavioral Health Practitioner, Pharmacist, MD) make unique and valued contributions to the care of all patients, expediting the care and recovery of patients.  We also have an active and successful nurse-advice service for our patients.

team

#3 Sharing Clerical Tasks Among a Team:  our Proactive Office Support (POS) nursing staff handle the non-physician parts of the workflow for medication refills, school/camp/work forms.

#4 Improved Communication:  through our redesigned process known as EDGE, the duration of time that lapses between an inbound patient-call or patient-email to the outbound resolution has been cut in half in many departments.   We’ve improved our co-location of physicians and advice-nurses in many departments as well, an important aspect of practice satisfaction (and efficiency) the researchers found.

#5 Improved Team Functioning:  team meetings answer the question “what’s working well; what needs changing?”, necessary to continuously enhance quality, workflow and efficiency (better care and less waiting for you!); we have a team-learning curriculum that leads to the elimination of holes in processes (“Highly Reliable Team Training”); team huddles in the morning anticipate individual needs of patients and team members.  Our practice engineers make our healthcare very safe and easier to navigate for our patients.

happy healthcare team

We are proud of our primary care physicians and their patient-centered practices – they lead to happy docs … the fuel that generates the best service and quality for you.

When Opinions Harm

If the soul of a free society is free speech, what role is the mind? Anyone and everyone has the right to express their opinion, but nowhere in our country’s founding documents does it say all opinions are based upon fact and reason, or equal in merit. Recent observations regarding the high and rising hesitancy toward childhood immunizations in our country have me thinking tonight about the tension between personal opinion and public harm … and the madness of crowds.

immunizations

In 1998, without scientific justification, British Surgeon Andrew Wakefield expressed his personal opinion that measles vaccination increased the risk for autism. Wakefield used wacky research practices, including drawing blood from children attending his kid’s birthday party, to amass fraudulent data that eventually led to his opinion being discredited and his medical license revoked. But the damage was done. British parents ignored recommendations from the Royal College of Pediatrics, and safety data from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC), in favor of one physician’s scientifically baseless personal opinion. Parents withheld measles vaccination from half the kids in the country for the next few years. As a result, today the UK is awash in adolescent measles, with some kids becoming very ill. Worldwide 400 people die of measles each day (WHO, 2011) mostly in Africa and Asia (meningoencephalitis), and many more become permanently deaf.

measles

In the US, unlike the UK, a child can’t attend school without receiving all age-appropriate vaccinations, but some moms still think they can “divine” an immunization schedule better than what the scientific method has determined and validated. And not just for the measles vaccination, but all of them. And what about the kids home-schooled who may receive no vaccinations? Those moms are certainly entitled to their opinions, but are they entitled to place their kids or your kids in harm’s way.

fact v opinion

Scientifically derived facts, when available, must govern the design and administration of our children’s healthcare, rather than opinion. But what caused the harm in the UK? Was it Wakefield’s bogus opinion, or that half the mom’s followed it, rather than scientifically rational recommendations from the Royal College?

KP 101: Our Results

2010-2012 HEDIS EOC, 15May2013

WE BELIEVE … our patients and families deserve the best clinical outcome possible from their healthcare. That’s why we work tirelessly, day and night, to achieve top honors in clinical quality year after year.  Indeed, NCQA has ranked KP Georgia #1 in the state for each of the last 8 years (since 2005). And we keep getting better each year.

JD Power

WE BELIEVE … our patients and families deserve the best care experience possible from their healthcare. That’s why we’ve created easy access to our doctors (more appointments to choose from, rapid response to email, and most telephone calls returned the same day). Our offices are brightly lit, comfortable and easy to navigate.  Our physicians run on-time the majority of time, which translates to convenience and respect for patients. Indeed, JD Power and Associates has ranked KP Georgia #1 in customer satisfaction in each of the last three (3) years – for Georgia AND the Carolinas.

2012 Aon-Hewitt HHVI results, most efficient 15May2013

WE BELIEVE … highly effective, patient-centered and timely care is also the most efficient care.  Americans need less redundancy of testing, fewer complications, and less waste of healthcare resources.  AonHewitt consistently ranks KP Georgia #1 in the state for efficient healthcare, and nearly 20% more efficient than average.

When the structure (see KP 101: our structure) of healthcare is designed right, good things happen for patients.  Our best-in-Georgia results, year after year, are a testament to that design.

Avoiding the ER

if disney ran your hospital, cover

Despite being in the very human business of relieving pain and suffering, US healthcare is more criticized for its poor customer service than celebrated for its user-friendliness.  For more information, one can begin with “If Disney Ran Your Hospital” (Fred Lee, 2004).

Ms. Jane Brody, the trusted columnist for the New York Times and best-selling author on matters of personal health for nearly 50 years, recently wrote an incisive piece detailing the inadequacy of care-choices after business hours in traditional healthcare (Avoiding Emergency Rooms, April 15, 2013).

jane brody

Ms. Brody hit all the low points of traditional American healthcare … (1) inability to reach the patient’s primary care physician for a simple matter, requiring an ER visit; (2) hours of waiting in the ER before being examined, (3) incomplete testing in the ER, requiring an otherwise unnecessary one-night admission to the hospital, location of super-bacteria and sleep deprivation, and (4) large financial waste.   She concludes “… the medical profession has thus far failed to adequately fill the gap left by doctors who no longer make house calls or answer the phone 24 / 7 / 365”.

TP ACC driveway approach

Well, we have at Kaiser Permanente of Georgia.

This month marks the one year anniversary of the opening of the first of four “Advanced Care Centers” (ACC).  Our ACC effectively addresses each of Ms. Brody’s criticisms: (1) open 24 / 7 / 365, staffed by physicians and nurses with excellent credentials and years of experience in emergency care, who are electronically and telephonically connected to the patient’s physician and her/his partners, (2) prompt and accurate diagnosis and treatment (time from walk-in to walk-out usually less than 2 hours, rather than the 4-6 [or more] in an ER), (3) a full complement of testing capabilities, including lab, imaging, telephonic specialty care AND if needed, quiet, comfortable, sparkling rooms to spend the night in the care of a hospitalist-physician, (4) at a cost lower than an ER copay/visit.  The nearly 2,000 patients per month that use our Kennesaw ACC have been delighted with the quality and service.  The second ACC will open in January 2014 at our Southwood campus in Jonesboro.

ACC room

As Ms. Brody says, “The overuse of emergency rooms is a growing and increasingly costly problem that results in overcrowding, long waits, overly stressed health professionals and compromised care for people with true emergencies”, the latter of which accounts for only 25% or less of patient visits to most ERs.  At KP, we are proud to be The Face of Future Care (see my previous blog post of this title).  TP ACC nurses station

Someone should tell Ms. Brody.

Putting the Crosshairs on Scope

For years, pharmacists, chiropractors, advanced-practice-nurses, podiatrists, optometrists and so on have fought in the General Assembly of the State Legislature for the expansion of their “Scope of Practice”, referring to the legal lines that define the limits of practice for a given healthcare practitioner, under state licensure.

MAG icon, high-resolution, July 2011For those same years, my beloved state physician association has fought on that same battleground, staunchly opposing such expansion of permissible practice for non-doctors.  This year was no exception.  MAG staff estimates they spend 70% of their year on this sole topic, giving less time to address other pressing matters (health insurance exchanges, payment reform, industry upheaval).

crosshairsPerhaps there is a more efficient way for the professional advocacy groups to spend our time.  Perhaps we can emphasize our common ground and explore root causes of the conflict, then seek a negotiated agreement for the betterment of Georgians and each professional discipline.  Perhaps its time to put the crosshairs on Scope.

Let’s begin with examining root causes of the conflict:

  1. some of the conflict has to do with money: by expanding the limits of practice for non-physicians, the latter can earn more money, at the expense of physician income
  2. some of the conflict has to do with clinical disagreement; podiatrists feel their (no pun intended) sole focus on the feet should empower them to perform more operations on the feet, whereas orthopedic surgeons feel their expansive training and surgical experience is better suited to create an optimal surgical outcome for complex conditions of the feet
  3. some of the conflict has to do with varying assessments of unintended risk to patients; what if, in giving pharmacists the right to administer pediatric vaccinations, kids saw their pediatrician less, leading to missed interventions for scoliosis, developmental delays, sexual health or abuse?

Beyond self-interests, I believe each professional group has altruism in their heart, wishing to improve the health of the communities they serve.  If so, could we agree that any negotiated change in Scope of Practice fulfill two premises:

#1 the proposed change in scope must have sound clinical evidence to support it (see my many previous posts on evidence-based-medicine [EBM]); for example, the requested increase in scope of practice must not only be supported by proof of expanded abilities of the health profession in question, but must also be proved (from a modest clinical trial) to likely “do good and no harm”

#2 the proposed change in scope must be in the public’s best interest (e.g., making low-risk influenza vaccine more accessible to citizens by granting pharmacists the ability to administer them)

team careMAG must maintain its role as the leading voice of Georgia healthcare. The citizens and legislature of Georgia will judge us by our ability to effectively work with, not against, the other healthcare constituencies who deliver care in Georgia.  Let us physicians make the first move to reach agreement on a scope of practice issue that promotes quality, access, affordability and safety with at least one of our healthcare colleagues in pharmacy, nursing, or another field before the 2014 legislative session.

Does Knowing Something, Do Anything?

L&D ward of the 1850s

The year was 1847; the place, Vienna Austria.  Many women were dying of “the fever” (infection) after childbirth … but mostly only if their baby was delivered by the doctor, rather than the midwife.    Dr. Ignaz Simmelweis figured out the reason, decades before Louis Pasteur and Robert Koch deduced germ theory.  Turns out the midwives washed their hands between deliveries, the docs didn’t. Nice.

simmelweis portrait ca 1857

For the last 150 years the medical profession has known that washing hands, vigorously and often, saves lives.  Yet plenty of observational studies in hospitals today reveal we doctors (and other healthcare personnel) don’t wash our hands as frequently as we should (i.e., prior to and immediately after touching a patient or bedside equipment).   For more information, read the recent series of articles in the Atlanta Journal-Constitution (AJC), “Hospital infections: deadly, preventable“.  Or if you prefer: Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009 Dec;73(4):305-15.

“I know how to fix that!” you say, “… just educate the docs to do it!”  Well, we’ve been educated about it for 150 years.  We humans (even altruistically minded, warm-hearted healthcare workers) don’t always behave according to “what we know”.  How many times have you run the yellow traffic light, when you “know” you shouldn’t?  How many times have you left your coffee on the kitchen counter, when you ‘knew” you wanted to drink it in the car?  How many times have you skipped your morning exercise, despite “knowing” how important it is to you?

sick of taking the blame for your shennanigans

In the realm of human behavior (and medical leadership, for that matter), this is referred to as “the knowing-doing gap”.  We imperfect humans, even smart, highly-motivated doctors, need help doing everything the patient needs, 100% of the time.   That’s the beauty of “systems-thinking”.

 

knowing doing gap, cover of book

You see, when hospitals increase the number of hand-washing stations, place alcohol foam outside every room, make available hand-lotion to prevent dry skin, and nurture an authentic culture of patient safety (all systems-thinking), patient infection rates fall dramatically.  Forward thinking institutions such as The LeapFrog Group routinely rank Kaiser Permanente hospitals tops in the country for all sorts of reasons, including lower rates of hospital acquired infections.

Systems-thinking works in ambulatory care too.  We have screen pop-ups in our electronic medical record (KP HealthConnect) to notify doctor and patient about needed preventive care, medication monitoring, or attention to a particular condition, even when that’s not necessarily why the patient came to the office today.  We also have a rich culture of patient safety – we train and practice the many techniques of “highly reliable teams”, with great results for patients.

mind the gap

I’m a lifelong advocate for education and a lifelong learner.  That’s why I know education has its limitations in optimizing human behavior inside an integrated delivery system. It pays to design healthcare knowing that human beings need workflows and information technology to cover their back, enabling optimally effective and safe care.

42

A fabulous movie got me thinking this afternoon about the desegregation of healthcare.

chadwick boseman at the plate

Witten and directed by Brian Helgeland, “42” captures the sheer courage, will and heroism of Jackie Robinson, the first black baseball player in the major leagues (1947), better than any screenwriter or director before.  Chadwick Boseman (playing Mr. Robinson) and Harrison Ford (playing Branch Rickey, the GM of the Brooklyn Dodgers 1943-1950), should receive Academy Award Nominations for Best Actor and Supporting Actor, respectively.  Mr. Boseman in particular captured the intellectual, emotional and athletic prowess of Mr. Robinson, including his swing and run.  A heroic story, told with authentic dialogue and set design, beautifully acted.

harrison ford as branch rickeyThrough the 1950s, separate (and unequal) hospitaIs were operated for African-Americans. In Memphis, where I attended medical school 1981-1985, I received some of my training in the EH Crump Hospital, built and opened in 1956 for black residents of the city. By the late 1960s, blacks in all regions of the country could use the same hospitals as whites, although in some states (Alabama), access was enforced by withholding Medicare payments to the hospital (see the history of The Mobile Infirmary). It would be another 20 years before Skilled Nursing Facilities (SNF) were truly integrated. But in any case, healthcare facilities of the South were integrated sooner than any other region of the US (J Health Polit Policy Law 1993 Winter; 18(4):851-869).

Many county medical societies of the 1950s and 1960s behaved more like autonomous physician fraternities than inclusive professional societies.  Separate associations were created by African American physicians, such as the Atlanta Medical Association (founded 1890).  Integration of nursing staffs preceded that of physician staffs, largely due to the operational impracticality of segregating them.

jackie robinson, right oblique profile

The personal dignity and athletic accomplishments of Jackie Robinson had an important role in shifting public opinion toward the integration of our society.  While manifestations of racism persist in our society (see the Trayvon Martin case), most have thankfully been vanquished from the medical profession.   We owe a little of that to Mr. Robinson.