Social Coordination of Healthcare

The whole costs less than the sum of the parts.

According to data collected till 2009 for the 100,000 Homes Campaign, about half of our nation's hundreds of thousands of homeless people have either a medical, mental, or substance abuse problem, and one quarter have all three. Unfortunately, their healthcare provider of choice--emergency departments--is the most expensive one.

Providing regular housing to homeless people on its own decreases their per-capita health care cost from $28,436 to $6,056, according to Boston's Health Care for the Homeless program. However, just as five percent of our country's population uses fifty percent of our healthcare resources, there is a similar stratification of need among the homeless. Patients with a cluster of chronic needs, or a debilitating condition that can be improved with a few weeks or months of treatment can be channeled away from acute care, if given assistance in navigating the healthcare system. Coordination of care by nurses and social workers connects them with primary care and this team combats the mental health, substance abuse, and social issues. Developing a first-name relationship and giving tailored, ongoing support, makes the difference in these successful programs.

Communities from Portland to Philadelphia are identifying and partnering with these homeless patients. In one success story, Portland's Recuperative Care Program has been taking high-need patients from the ER into a 30-day medical home and assigning them care coordinators, and has reported rates of 74% medical recovery and 61% discharge to stable housing. Oregon Health and Science University hospital leaders report that since 2005, they paid $500,000 to the program and thereby saved $3.5 million in costs, by reduced retreatment visits in the ER. At the heart of these results are care coordinators who know the patients personally, and help them execute primary-care centered, long-term plans.

System-level healthcare integration is not only important for the homeless. Disjointed, high-cost, acute care for the homeless is reminiscent of our broader system. Truthfully, few of us find a medical home. Perhaps these programs are the first stones to be thrown in a Copernican Revolution which recasts the patient at the center of our medical system. Patient health at the bottom line is the organizing principle, and primary care is the organizer. Without them, specialty interventions become so many soldiers without a general or a plan.

Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. Institute for Healthcare Improvement white paper.

Electronic Access vs. Safety

I was listening to public radio cruising north on 59 toward LBJ when I heard Dean Sittig discussing a new study on privacy in electronic health data. A study by PriceWaterhouse Coopers suggests that privacy standards are not keeping pace with access to health care information. Health care workers are gaining increased access to protected health information (PHI) on mobile devices at the risk of these devices not having sufficient privacy standards to prevent security breaches.

This was fascinating to me because Memorial Hermann just released Care4 access to iphone and ipad users. Is this access necessary and reasonable to allow doctors to treat their patients appropriately and effectively? To be sure, handheld electronic devices are commonplace among physicians, residents, and students alike. I have been using my ipod touch (because I refuse to pay the outrageous data fee for any smartphone) consistently to look up dosages on epocrates. Similarly, one of my residents rarely uses paper for rounds, but rather his ipad for access to Epic. Would it be more convenient for me to look up a patient’s recent BMP while walking without having to sit down and log into a computer? Probably, but I’m unsure whether the benefits outweigh the risks.

The trouble with the study is that it doesn’t seem to offer any answers, similar to much of the research done so far in electronic health records. I’m left with an uncanny feeling of uncertainty about current policy regarding handheld devices and access to PHI.

You can listen to Dean Sittig’s 1 minute NPR clip right here.
http://app1.kuhf.org/articles/1316724294-Study-Suggests-Healthcare-Industry-Falling-Short-In-Protecting-Digital-Records.html

Rural Research

A recent article in the British Medical Journal, by Perry, et al., presented evidence that a CT scan within 6 hours of symptom onset yields 100% sensitivity in the diagnosis of subarachnoid hemorrhage (SAH), when read by a trained radiologist. The results suggest that in this setting the need for lumbar puncture (LP) is greatly diminished. If this data is trusted, and physicians use the CT scan as the Gold Standard, then an invasive procedure may be avoided. Currently, when a CT scan doesn’t highlight any blood, physicians are likely to order an LP to be certain that SAH is safe to rule out.
Citation: BMJ 2011; 343:d4277

However, this study is concerned with the utility of CT, not making LP obsolete. In 2008 I detoured from a cross country move, to drive through a small Kentucky town, after a sign for a hospital drew me off the road. Banners hung across the hospital’s entrance to celebrate its recent implementation of a smoke-free campus. I wonder whether the benefits of CT or smoking cessation was the first to affect the practice of those physicians.

Even without the evidence demonstrated in the Perry study, hospitals in the Texas Medical Center have long been using CT to aid the diagnosis of SAH. This study justifies ordering a CT scan to identify subarachnoid bleed when there is a suspicion of SAH. While its data is not game changing along Fannin Street, it does reinforce CT scans’ legitimacy as a covered diagnostic test, even by the stingiest of health insurer.

As the indicated uses for CT broaden, perhaps rural hospitals are more likely to purchase the advanced equipment. However, in the near term, it’s critical that research begin to focus on the way medicine is practiced in these rural areas. To do so requires dedicated NIH grants stipulating funds be spent in a rural setting.
Conducting research in this manner would inform us of the methods rural physicians use to make a diagnosis when using a less technologically advanced toolbox. Likely, we’d learn something from their practice, or maybe we’d remember things our profession has largely forgotten. But more importantly, we’d face a reality that medicine must be practiced differently by people living in rural areas.

Today’s rhetoric favors preventative medicine and seems to delight in our failure to prevent disease. Politicians introduce the topic as if they originated the idea of prevention, and admonish physicians for not participating in their unnamed solution. The natural reaction is to parry, "Society as a whole fails to take the responsibilities necessary to prevent disease; this is not the fault of physicians." Rather than join in meaningless debate, the physician profession must lead improvement. One action is the research of Primary Care methods, with aims to determine how to better prevent disease.

Today, it’s not uncommon that complicated patients in rural, East Texas be transported to Houston for higher level care. A tenet of Quality Improvement is that transportation is waste. While the patient is moved, the standard of care is temporarily lowered. Currently, the vast majority of research is conducted at tertiary care referral centers. Broadening our focus of research to include rural areas, in addition to tertiary care centers, would bolster the quality of care provided in the rural setting. Where academic researchers travel, medical residents and fellows follow, in search of training. As the government begins taxing Graduate Medical Education programs, the already meager resident salaries will thin further. A number of medical school graduates are likely to appreciate the opportunity to train in a location where their salary offers a higher standard of living.

Several factors may converge to favor the development of rural medical care. By studying the patient populations in the primary setting we’d learn more about prevention.

Heads Down, Thumbs Up

Acute ischemic stroke patients may benefit by simply lowering the head of their bed. An inverse relationship was demonstrated between bed angle and residual blood flow to ischemic brain tissue. Similarly, Jugular Venous Distension becomes clearer when a patient is reclined. Therefore, this finding is not totally surprising. What is compelling is that the improvement is distinct and occurs even across small gradients: 15 degrees is preferred to 30 degrees even if not as ideal as a patient laying flat.

Clinically implementing the finding still requires a bit of common sense judgement. Patients with dysphagia are at an increased risk of choking which is greater when they lay flat. Because the same patient who has suffered a midbrain stroke is often dysarthric, they are at risk to silently aspirate. A real risk of choking must be weighed against the perfusion benefit described in the study. Occupational therapy can help in the management of these stroke patients.

While the hospital bed controls which set head angle are simple, keeping a patient's head down can be more complex. Patient compliance is required. Those short of breath when laying down (orthopnea from Congestive Heart Failure), and those prone to choking (dysphagic after a midbrain stroke) desire to sit up. Many stroke patients spend the first hours after the diagnosis of stroke in the ER. Therefore, the ER staff must also understand the importance of heads down just as well as the specialized staff of a dedicated stroke team. Even once admitted to a stroke unit, visitors may raise a patient's head earlier than is desired. Technicians who perform cardiac echos may raise the bed or ask the patient to prop themselves up, into positions which obtain a better ultrasound image. A well-meaning family member will often raise the head of a patient's bed, allowing the patient to more easily see and interact with family, at the expense of critical perfusion.

The heads down study has encouraged neurologists to emphasize a seemingly small detail to physicians and practitioners outside their specialty. It can be found by referencing: Neurology. 2005 Apr 26;64(8):1354-7.Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Wojner-Alexander AW, Garami Z, Chernyshev OY, Alexandrov AV.

"Ischemic stroke is a potentially reversible process that is dependent on restoration of arterial blood flow within a window of cellular viability that varies according to the severity and duration of the flow deficit. Measures that promote blood flow during the acute phase of ischemic stroke may directly impact the subsequent development of brain infarction and associated clinical deficit. One such measure may be flat head-of-the-bed (HOB) positioning to promote a gravity-induced increase in arterial flow to ischemic brain tissue; however, patients with stroke and other neurologic diagnoses are routinely positioned using 30° HOB elevation by paramedics and emergency room personnel."

Source: Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA

Photo by Flickr user: chimothy27

Fishbone Diagram: Promotion Category

Product Place and time Price Promotion Process People Productivity Purpose

There are many strategies for well run promotions. The AMA employs a promotional strategy to gain members by allowing medical students to join at greatly reduced rates. The AMA follows a strategy that uses elements of discounts, limited time offers, and versioning.

Hopefully, for the individual medical student, the discounted rate is a limited time offer and they are eventually eligible for the more expensive physician rate. The experiences available as a Student differ slightly from those enjoyed by a Physician. The distinction between these two versions is most evident during the National Meeting when two separate House of Delegates are maintained in a fashion similar to a House of Lords (Physicians) and House of Commons (Student section).

Versions work best when different tiers more closely approximate the individual needs of users. For example, only the most gunner Medical Student would think that they benefit professionally from spending time in the Physician House of Delegates. While the pomp and circumstance of that venue is an enriching experience, the small talk with physicians that ensues is unlikely to make a lasting impression. Working with peers has more peripheral benefits. The versions employed by the AMA appropriately assign members to work with their colleagues and are priced accordingly.

Simplifying the Square

A goal of 2directions is to help physicians win the corner office at the hospital and to begin making business decisions in the best interest of the Patient-Physician relationship.

To weigh interests, business schools teach a simple method: ask two dichotomous questions and plot the answers on a 2 X 2 square. Along one side, are the responses to the effect of the action on customers as either Good or Bad. On the other, the same consideration is made, this time regarding the effect of an action on the business itself. Answering these two questions allows quick analysis of whether a project should be pursued, weighed, or rejected. The resulting grid is reminiscent of the Punnet Square. Homozygous recessive is akin to the elusive win-win, while the Heterozygotes fall in the more common grey areas.

While you wouldn’t always think so, MBAs prefer projects which are good for both the customer and the business. However, the MBA doesn't shy away from actions which are unfavorable to one of the two parties so long as the actions are strategic and maximize the long term value of the firm. Mixed responses to the two questions introduced above lead the MBA to consider options, with an eye for the long run, the MBA attempts to maximize profits without losing its best customers.

"Promotions" are actions which benefit the customer more than any harm done to the business. When judged correctly, promotions have a high transaction value even though they may be unfavorable to the business. Groupon capitalizes on this strategy by helping business to generate awareness and goodwill. The business shares with customers the majority of the value it creates. Actions which benefit the customer but aren't necessarily good for the business accumulate Goodwill. Later, the business will have an opportunity to take actions which favor the business at the expense of the customer.

A recent example of cashing in on Goodwill is Netflix upsetting customers by raising its rates and enacting separate billing for postal delivery of DVDs and streaming video. Undoubtedly analysts demonstrated the move is good for Netflix, despite the fact that customers will be lost. Clearly, those customers who stick it out receive less value now that the same product carries a higher price. In the future, greater customer value may return if many more movies are available to stream. Should that happen, customers who are satisfied by streaming alone might discontinue postal DVD delivery, a choice they would otherwise not give much thought to without separate billing. Since the cost to Netflix is greater to ship a DVD than to stream a movie, Netflix will benefit when consumers change their behavior. By billing separately, Netflix encourages customers to drop DVD delivery so that in the future Netflix might discontinue its postal service with less guilt. Despite the fact that customers don’t benefit by this path, the decision supports Netflix’s long term goal to yet again revolutionize the way we watch movies at home.

Should physicians give in to perverse incentives, they breach their fiduciary duty to patients. Whether motivated by greed or the practice of defensive medicine, these actions increase the cost of care without adding value. On the other hand, an action which is not in the best interest of the physician and benefits the patient should be taken. Indeed, a criteria of a profession is to only take actions which benefit the customer. Currently, many hospitals are run by CEOs who approach decisions as an MBA would. To maintain service, and ensure it stands for future generations, physicians must be mindful of when actions harm the business. On average, most decisions the Physician CEO makes would need to benefit the business. However the MBA's approach could be simplified by omitting any option that is not good for patients:

Price doesn't equal Value (Fishbone Diagram)

Product Place and time Price Promotion Process People Productivity Purpose

When setting prices, a business avoids going too low. Of course, we understand this fails to maximize profit. More importantly, consumer behavior demonstrates that a product which is sold for a lower a price than its competitors, is first considered a value. Eventually, the price difference becomes too great. Then the discount is no longer judged to be a better value, and begins to suggest that the product is inferior. For many consumers, the product which they believe has the most value is the second most expensive. For this reason, a business will develop a luxury version of their product. While it may manage to sell a few of these highest end items, more benefit is derived by the now second most expensive item being perceived as a better value.

The price schedule for the AMA is cheap when compared to other professional organizations such as that for trial lawyers. Could the low cost lead many physicians to question how relatively inexpensive professional organizational fees can return value? What if the annual dues were doubled? Would physicians anticipate more value and respond by joining the AMA?

Zane highlighted that much of the cost of participating in the AMA is incurred by traveling to the national meetings. His recognition again raises the question whether a national organization is needed. Or, perhaps Annual and Interim meetings are not regularly required. More productive work may be invested in local improvement, rather than preparing for the next national meeting. When the total cost of participation is largely related to travel expenses, then the disconnect between price and value widens further.

Reviewing the price we find a lot of wasted value. This concept of waste, arises repeatedly in medicine. In the case of the AMA annual events the waste takes the form of travel. Going to Chicago is a fun time, no doubt. However, many physicians would just assume take a legitimate family vacation. Travel to Chicago for CME and professional development workshops allows value to dribble away as hotel receipts, cab fares, and hasty lunches.

Instead, physicians could receive more value by attending regular meetings at which local financial consultants educate attendees on choosing a medical equipment loan from options locally available. They would attend such conferences with neighboring physicians and discuss the local problems they face. Rather than mulling over what they'd like to do about those problems, then only delivering their decision as a single vote to a national legislative body, they could take action--locally and immediately. Of course there are national problems physicians face which require a national organization. One such problem is how to best adopt EMRs to achieve the furtively defined, "meaningful use." Perhaps a local forum in which physicians can offer lessons learned from their adoption of EMR would be more beneficial. As more and more small clinics merge to grapple with increasing overhead, the need to know local fellow physicians increases.

Now, we'll put more meat onto our Fishbone Diagram. The new problems identified:



By picking apart price, we have noted additional problems with Place. Creating a fishbone diagram should allow this sort of active brainstorming. We can quickly categorize this newly identified problem under its appropriate Place label as we fill in the Fishbone Diagram.