Clinical Integration – The Link to Special Relativity

einstein1Journalists ask, ‘What does Clinical Integration look like?’  Like Albert Einstein wrote in 1905, it depends upon the observer.

To the patient, its better care experience due to more appointments, easier appointing and navigating, all information available in the moment of shared-decision-making, and all clinicians seem to know each other and trust each other. And that care experience is predictable and reliable (standardized) regardless of the location in which he/she receives care.

To the system-wide CFO, its higher margins for a single clinical service line or all service lines. For example, the production cost of total hip arthroplasty rises year-over-year at a rate less than the rate of revenue for that procedure. That margin occurred because the docs, nurses, pharmacists, physical therapists, improvement engineers and case managers collaborated to reduce (a) clinically unwarranted variation in physician practice patterns and (b) wasteful team workflows.

To the doctor, it’s better professional fulfillment because she doesn’t have to fight as hard for her patient to receive a prompt, goal-directed consultation in Neurology or well-organized home care following hospitalization. A reduction in the time that elapses between onset of illness and definitive treatment is a reliable marker for Clinical Integration (CI); if cycle time doesn’t fall when compared to baseline, CI wasn’t created  (see http://www.drrobschreiner.com/uncategorized/clinical-integration-the-essence/ ).

To the ICU nurse, it’s fewer terminally ill patients on the ventilator, because the Palliative Care consult was performed 6 days after diagnosis, rather than 6 days after intubation.  And she has 3 physician caring for Mrs. Brown, with one of them conspicuously serving in the role of Attending Physician, rather than 6 docs with no Attending.

To the system quality officer, it’s higher HEDIS scores, better Joint Commission appraisals, and fewer events of patient harm or allegations of medical-malpractice, because of less clinically-unwarranted variation in the practice patterns and workflows for patients with similar conditions.

To the Brand & Marketing Department, it’s more patient testimonials on Facebook for why care at St. Neighborhood is better than care at St. Midtown.  And they have more requests than ever to sponsor branded public events.

To the CEO, its higher margin and marketshare over time (lagging indicators), due to the success of the colossal changes in operations, informatics and culture depicted above (leading indicators).

So the manifestations of Clinical Integration, like space and time, depend upon the observer, just like Einstein said.

einstein

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).

Adult Vaccination Rates – another missed opportunity by the media

Mr. Paul Galewitz of USA Today missed an opportunity in his article last week (http://www.usatoday.com/story/news/2015/09/12/kaiser-ouch-vaccination-rates-among-elderly-lag/72147204/) to do something The New York Times and The Wall Street Journal routinely do … provide insight to the lay public regarding what really works to improve healthcare outcomes in the US.


Lance McCord / Foter / CC BY-NC-SA

Mr. Galewitz very appropriately calls out the low US vaccination rates in seniors for influenza (65%), varicella (24%), pertussis (50%) and pneumococcus (60%), but fails to report on the well-published science of what health systems can do to make those rates higher.

Instead, Mr. Galewitz uses his airtime to quote doctors who believe (a) it’s the patient’s responsibility to know what vaccines they need (Dr. Robert Wergin, president of the AAFP), (b) billing Medicare administrators is complex (Dr. Reid Blackwelder, chairman of the AAFP), or (c) the main reason for the low vaccination use is the lower effectiveness of adult vaccinations when compared to childhood vaccinations (Dr. Bruce Gellin of HHS).  Ugh.

Here’s what Mr. Galewitz should have reported:

“Every year, 5% of the health systems and doctor’s offices in the US achieve the highest vaccination rates in the country (for example, see any of the 6 Kaiser Permanente regions, for both adult and childhood vaccinations).  That begs the question, ‘What are those doctor’s offices doing that the bulk of US physician practices are not?’  The healthcare industry has known that answer for the last 15 years, yet it hasn’t spread those best practices.  Why is the spread of best practices so difficult for the US health system?”

Anyway, here’s the list of what works for adult vaccinations (see sources below):

  1. Non-physician staff (receptionists, MAs, LPNs, RN’s) assess vaccination needs for each patient prior to the physician walking into the exam room
  2. They communicate a strong recommendation from the physician to vaccinate, which the physician reinforces if needed
  3. The care-team addresses misconceptions head-on (e.g., “the flu vaccine can NOT give you the flu”; “the shingles vaccine does NOT mean you were a bad person in your younger years” [Wikipedia describes it as a herpes virus]; “What are the barriers to you receiving the vaccine today?”)
  4. Physician-directed nurse protocols provide the vaccination before, during or after the visit
  5. EMR-prompts (such as EPIC’s Best Practice Alerts), provide the safety net

Rather than point to pop culture bling (these days everybody believes Uber will solve the world’s problems), Mr. Galewitz missed an opportunity to tell his readers how to recognize better healthcare when they see it (the list above).  He gets one thing right though – he highlights one practice (University of Pittsburgh Primary Care) that increased its vaccination rates by 40% in one year (!!) by deploying the front office workflows and nurse protocols described above, but he buries that point at the end of the article; most readers probably gave up by then.

Jan 2000 – Am J Preventive Medicine

June 2005 – Hopkins NS, Shefer A, et al.  Am J Preventive Medicine 28:5S

April 2015 – http://www.medscapte.com/viewarticle/842874

Spare Me the Subjective and Objective; I seek the Assessment and Plan

It’s easy to find a well-done study to affirm how anxious and unhappy we physicians are these days. For example, the October 2012 Merritt Hawkins / Physicians Foundation survey of nearly 14,000 physicians paints a picture of individual pessimism and professional decline (see table below).

The Physicians Foundation & Merritt Hawkins, October 2012

%

Pessimistic about the future of the profession

77

Morale described as “negative” for self

58

Morale described as “negative” for colleagues

80

Profession described as “in decline”

84

Willingness to Recommend Profession to Children / Young

42

It’s harder, and perhaps more meaningful, to interpret the subjective and objective. Indeed, I suggest we stop “interviewing for pain”, and start crafting an Assessment and Plan that might improve things. Lesser physicians spend the majority of their time transcribing data into the subjective and objective portion of their progress note; greater physicians spend that time interpreting the data and crafting a path toward recovery.

The root causes of our pain seem to be (1) reductions in our autonomy (for diagnosis and treatment; for running our practice; for regulatory and contractual reasons), and (2) issues related to money (decline in payment amount per unit of care, thus driving higher number of units; patients changing doctors for coverage/cost reasons; a belief that one must work more hours for the same pay). Interestingly, these root causes have been the industry’s intentional response to the ridiculously high cost of American healthcare, as well as inadequate and unreliable clinical outcomes of that care. We physicians failed to solve the problem of runaway costs over the last 30 years, so payors sought to solve it for us by reducing our decision-making autonomy and payments per unit of care. Those “interventions” failed of course, but that’s a different article.

Our Plan must account for the root causes of the disease:

  1. If we believe (a) unwarranted variation exists in the practice of medicine and surgery, (b) some unwarranted variation leads to wasted resources and lesser patient outcomes, and (c) Evidence-Based Medicine (EBM) can reduce some of that variation, then we physicians should collaborate to create, adopt and continuously refine Best Practices, rather than lament loss of individual physician autonomy.
  2. If we believe (a) earning a salary in the top 2% of American society is sufficient compensation for our years of personal sacrifices and professional pressures, (b) being invited into the lives of people when they are most vulnerable is a unique privilege, and (c) easing pain and suffering is meaningful work, then we should emphasize a personal perspective reflective of those blessings, rather than continuously mourning the massive changes in our practices.
  3. If we believe (a) fee-for-service (FFS) compensation promotes volume over value and can misalign patient and physician interests, (b) having administrative infrastructure frees physicians and surgeons to do more of what they like to do, and (c) practicing in a fellowship of collegiality and comradery leads to professional fulfillment, then we should form self-governing multi-specialty group practices, in which each physician is accountable to one another along dimensions of quality, citizenship, and work ethic.
The Plan

% of the solution

Create, adopt and continuously refine Best Practices, led by physicians

20%

Practice a personal perspective that reflects the blessings of our profession

30%

Form large, self-governing multi-specialty group practices, organized around the principles of humble service, patient-centered care, and continuous improvement

50%

We must stop focusing on our personal and professional pain and start focusing on how to restore the fulfillment, the culture of humble, altruistic service, and the scientific method to our beleaguered profession.

Better Than a Necktie

We fathers are most comfortable giving advice to our sons and daughters about school, careers and sportsmanship.  But what if discussing a different topic altogether was a stronger determinant of their future happiness, safety and success?   What if we made it our priority to have a conversation with our children about the importance of healthy relationships?  We might find the topic uncomfortable, but we have to be the ones to discuss it with our kids, not just mom.  It may be one of the best gifts we can give our families – and ourselves.

father talking to son

The ability to have and sustain a healthy, mature relationship, built upon respect and trust, is more important than many things we dads teach our kids. Yet my 28 years as a physician show few of us fathers formally teach our kids about such things. Our silence in this regard may leave them unprepared to prevent or avoid domestic violence, sexual assault or stalking by an intimate partner.  I firmly believe that by talking about the problem and educating our children about healthy relationships, we can indeed reduce the violence and protect all children, now and later in life.

The fact is we all have to engage in this process if we are ever going to reduce the prevalence of domestic violence and sexual assault in our society. According to the Centers for Disease Control (CDC), every minute, 24 people in the United States are victims of rape, physical violence or stalking by and intimate partner. Georgia is ranked 10th in the nation for the rate at which men kill women, in single-victim homicides, most of which are domestic violence-related murders.  Not only can conversations help protect our own children, but in having these conversations, each of us then plays a role in addressing this issue in the larger community.

That is why I am supporting a new effort called NO MORE, which through a new bold symbol,  is bringing together all people and communities that support ending domestic violence and sexual assault in our society.  A key focus of NO MORE is to involve men in raising awareness for these issues.

We are accustomed to women talking about the problem, but men can have a more powerful impact on their sons and daughters, particularly because it is unusual to hear this message from us. And Father’s Day gives us the opportunity to initiate a conversation with our kids about what is healthy and unhealthy in relationships. In the process we can teach them that violence and abuse, power and control, are never OK.

father talking to son in sunset

The critical first step is to know the best way to initiate these talks. It may not be our natural style, but it is helpful to start the conversation with questions, rather than lecture with statements. And of course we should let our kids’ maturity and context guide us in asking these questions. For example, you may want to ask, “Have you read any articles or books about domestic violence ?  Do you and your friends talk about this topic? What questions do you have? ”

NO MORE

Or another way to approach the conversation is to ask, “Have you ever been worried about the safety of a friend in a relationship?  Do you feel comfortable offering help, even when you have only a suspicion of a problem, rather than proof?”
Plenty of other recommendations for the conversation exist, easily found at www.nomore.org. Dads can learn how to talk to their sons about healthy relationships at www.mencanstoprape.org and www.acalltomen.org/.”

So with this information, how about we fathers have a conversation with our kids this Sunday about how to create and maintain a healthy relationship, and how to identify the warning signs of a relationship that may lead to domestic violence.  It’s more worthwhile than necktie.

KP 101: Our Research

senior woman walkingWE BELIEVE … we have a duty to continuously improve our care, advance the knowledge of our profession, and improve the lives of not only current members, but future generations as well.  That’s why we measure nearly everything we do for our patients, giving us the necessary insight to better prevent or cure disease.  For example, 10 years ago our Southern California colleagues worked out a way to prevent the majority of bone fractures in older women, saving thousands of members the pain and suffering of a hip fracture (our Healthy Bones program).

pertussis

WE BELIEVE … we make a unique contribution to healthcare research.  We have over 1.5 million clinical office visits per year in the Georgia region, in addition to thousands of hospital and ER visits per year, all in the hands of our Permanente Medical Group. That volume of detailed patient experience is a very powerful research tool, enabling us to answer clinical questions that other institutions can’t. For example, this month our KP Vaccine Study Center in California reported upon the effectiveness of the current pertussis (“whooping cough”) vaccine, made possible by studying the outcomes of 55,000 KP members. Our results will likely lead to changes in the use or composition of the vaccine, better protecting kids and adults in the future from that dangerous infection.

pharmaceutical safety

WE BELIEVE … in optimizing the safety of healthcare through the research we conduct.  As a result, our patients receive care backed by evidence of benefit and reflective of the latest knowledge.  For example, when the use of a new class of anti-inflammatory medications raged in the US ~2000 (“COX-2 Inhibitors”), we (1) limited their use in our patients until the medications could be better tested, then (2) provided key research data to the FDA showing a link to heart attacks and strokes for certain patients, eventually leading to the withdraw of many of those drugs during the last decade.

WE BELIEVE … a very important, yet often overlooked method to improve the clinical care and service experience of patients lies in first studying, then improving the workflow of the healthcare team. That’s why we’ve heavily invested in patient-centered process improvement at KP. For example, we’ve improved appointment availability (now same-day or next day for your Primary Care Physician), reduced wait-times in our offices (often no wait at all), and improved turn-around-time of phone and email messages (usually within hours).

The research we do directly helps our current and future members, both in terms of their health and their care experience.  We are proud of that part of the KP legacy.

About the Kaiser Permanente Vaccine Study Center
Founded in 1985, the Kaiser Permanente Vaccine Study Center began as a way of responding to numerous requests to use Kaiser Permanente’s large member population for vaccine efficacy studies. Key studies have focused on Haemophilus influenza, type B (Hib), chickenpox, pneumococcus, rotavirus and flu vaccines. The center participates in several Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) studies. For more information, visit http://dor.kaiser.org/external/DORExternal/vsc/index.aspx.

dept of research and eval

About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and the society at large. It seeks to understand the determinants of illness and well-being and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600+ staff is working on more than 250 epidemiological and health services research projects. For more information, visit http://dor.kaiser.org.

The Military Ideal of Duty and Service applies to Medical Leadership

heartbreak ridge

At the age of 19, he and his mates in Company I, 23rd Infantry Regiment were ordered to make an assault straight up the rocky, heavily fortified mountainside near Chorwan, North Korea.  The men clambered up the slope taking out one enemy bunker at a time; those who made it to the crest alive sustained the inevitable North Korean counterattack that night, while exhausted and low on ammunition.

heartbreak soldier comforting another

And so it went for 30 days and nights in September-October 1951 – a day’s ascent often followed by the night’s retreat.  Vertical trench warfare.  What began in the morning with tanks, artillery, and air-cover often ended in hand-to-hand combat in the pitch of night.  Entire Companies of 100-200 men were wiped out.  I am told that my father was the last man standing in his unit after defending his position all night with a machine gun, a knife and a few grenades.  The Battle of Heartbreak Ridge, The Korean War.

He was promoted to Sergeant, First Class in the middle of the battle.  This morning I reread the letter of promotion from Major General Robert Young:

“One of your first duties is to the men under you; get to know them and their capabilities and limitations, see that they are taken care of, do everything you can to solve their problems. In addition, you must set an example to your men in appearance, discipline, courtesy and professional skill, whatever your primary duty may be … Why will you do these things?  Because you are a leader.”

Private Grey in color guard, ca 1950

I am in no way comparing the brutal life-and-death of battle to the air-conditioned environment of medical leadership. I’m saying the miliary ideal of duty and service to those in our unit fully applies to medical leadership.    Do we reliably treat our colleagues with courtesy?  Do we take care of one another?  Do we solve problems?  Those of us entrusted with the privilege to lead must continuously ask, “Am I doing enough for my colleagues?”

In anticipation of Memorial Day 2013, Schreiner reread Citizen Soldiers, by Stephen E. Ambrose, published 1997.

KP 101: Our Philanthropy

charmaine kneeling to child and mom

WE BELIEVE … we have a responsibility to care for our communities, not only our members. That’s why we invest over $30M each year here in metro-Atlanta on a wide array of philanthropic activities (our Community Benefit Program). Check it out …

 

atlanta beltline arboretum logo

WE BELIEVE … all healthcare entities have a responsibility to provide charitable care, and indeed we do, not only through the direct care we provide to the disadvantaged, but also through grants to many hospitals, clinics and outreach programs in the area.

everybody walk

WE BELIEVE … health education is important for all ages. That’s why we have a very active Educational Theatre troupe who perform around town, entertaining audiences with creative content about health and wellness. We are sole sponsors of the Beltline Arboretum Docent Program.

WE BELIEVE … an active lifestyle is one of the most important components of health. That’s why we’ve invested in the Atlanta Beltline, Park Pride, the Every Body Walk! campaign, as well as fitness programs for schools.

earthshare of GAWE BELIEVE … a healthy environment is a necessary part of living in Atlanta. That’s why for years we’ve supported EarthShare of Georgia, Trees Atlanta and the creation and maintenance of other green-space throughout the city.

piedmont park green marketWE BELIEVE … a healthy diet is critical to a healthier you, and we acknowledge that not everyone in Atlanta has easy access to affordable fresh produce. That’s why we’ve sponsored the Piedmont Park Green Market, and other Farmers Markets / Farm-to-Table initiatives.

Through our Community Benefit program, we improve the lives of kids, parents, and hard-working Americans in the communities we serve.

Lies From the Pits of Hell

neil young, early performance

I love Neil Young for the totality of his work, but especially After the Goldrush (1970) and Harvest (1972).  That said, I think Lynyrd Skynyrd had it more right (“Sweet Home Alabama” v “Southern Man”): we Southerners are best judged individually, just like every other American.  I imagine Neil would agree today.

lies straight from the pits of hellNevertheless, it pained me to hear Georgia Congressman (and physician) Paul Broun say last month “… what I was taught in school … evolution, embryology, The Big Bang Theory … are all lies straight from The Pits of Hell!” (see recent YouTube video from the Liberty Baptist Church, NE Georgia).

renaissance man, leonardo's sketch

His words pain me because I am a proud Georgian.  And a proud Man of Science – indeed, a physician.

So for those of you who live in other areas of the country, and doubt the intellectual and creative capacity of your Southern Brethren, hear me when I say … don’t make the same mistake Neil Young made 40 years ago … Paul Broun does not define Georgian men, nor Georgian physicians.  Let’s hope not anyway.

 

Symbols Can Change the World

pinkribbon1973. My high-school friend arrives home from school to an empty house. Since being told 2-weeks earlier she had breast cancer, his Mom had been silently making arrangements for surgery in another town. Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 40 years – we’ve got races for the cure, pink shoes on NFL players, survivorship celebrations, a whole month of awareness during which time you better show up at work with a pink garment at least twice a week, or you don’t fit in. What helped the world change?

 

redribbon1983. I’m holding the hand of a terrified 24 year-old man dying of progressive respiratory failure, brought about by an immune deficiency syndrome we poorly understood. Other than me and the nurse, he’s dying alone. Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 30 years – we’ve got celebrations, empathy, acceptance. Heck, we got Bono. What helped the world change?

 

couric2003. I’m writing a letter of condolence to the widow of my medical school friend, recently passed away from colorectal carcinoma, leaving behind a now single mom and young children. But I’ll get my screening colonoscopy next year, once I lose some weight (perhaps I’m embarrassed to be seen with only a hospital gown). Neither disclosure nor discussion with family and friends, just shame and fear. Scroll forward 10 years – we’ve got colon-prep-parties, a month to call our own, rising screening rates. What helped the world change?

 

nomore2013. Women are stalked, spouses battered and imprisoned, children scarred. Inadequate disclosure, inadequate discussion, just shame and fear. What can help change the world?

Throughout human history, we’ve used symbols to recognize, remember, and reform our world. Symbols can be particularly useful when addressing public health scourges. Linking the thousands of people, working in hundreds of non-profit organizations, who use many great programs to prevent and intervene in domestic violence and sexual assault, we now have this singular symbol. Wear it with pride. You might just change the world, one silently suffering person at a time.