ClickCare Café

Why Opioid Overdoses Spotlight Care Coordination Failures

Posted by Lawrence Kerr on Thu, Feb 21, 2019 @ 06:00 AM

tom-parsons-426898-unsplashThe US opioid epidemic is reaching unprecedented levels. Almost 48,000 people died of an overdose in 2017 and millions of people are affected by opioid abuse. 

One challenge in the treatment of opioid abuse and overdose is that they lie at the intersection of multiple disciplines, providers, and dynamics. Mental health, public policy, law enforcement, social work, housing, emergency care, and medication all play a role. But too often, only the immediate problem is addressed -- and care coordination fails -- which means that patients end up experiencing chronic repetition of that problem. 

A recent study looks at why opioid overdoses reveal the significant cracks in the care coordination that exist -- and endanger all patients.

You could say that West Virginia is Ground Zero for the opioid epidemic. The state has an opioid overdose rate more than three times the national average and the highest death rate from drug overdoses in the country. So the challenges that patients and providers face there are instructive for providers in states with less severely affected populations but who face similar dynamics.

In an effort to understand the trajectory of care for these patients, Fierce HealthCare looked at a recent West Virginia study of Medicaid claims. Researchers followed the treatment of patients after the overdose code to see whether follow-up care was billed. For instance, checking to see whether mental health visits, opioid counseling visits or prescriptions for psychiatric and substance abuse medications were billed after the initial Emergency Room care. 

Following ER care for an overdose, less than 10% of patients received a substance abuse drug and fewer than 15% received mental health counseling. Of course, it’s possible that the rate of referrals was higher and that many patients didn’t access the counseling. But realistically, follow-up may be as crucial a part of the care as the initial care itself. As one patient who was treated for an overdoes in the ER said, “There were a lot of times I could have gone down a better path, and I fell through the cracks."

I noticed several key insights from this study that I think are meaningful for any provider, regardless of how relevant opioid abuse in particular feels to them. 

4 key learnings from opioid overdose and care coordination failures:

  • The more complex the disease, the greater the risks for coordination.
    But "complexity" doesn't just come from the details of the disease itself. In opioid abuse, multiple parties, including healthcare providers and social services all need to come together to care for the patient effectively. And these providers must collaborate across institutional lines, across the continuum of care, and across a long time horizon. This complexity is where we start to see care coordination fall apart -- but really it just reveals the weakness in care coordination that exists for all patients.
  • Some diseases are associated with less sympathy than others. 
    The reality is that with drug overdoses, there may be an aspect of moral condemnation in the ways that healthcare approaches the problem. As healthcare providers, we know that opioid abuse is really a complex disease. But it's very possible that bias sneaks in and the complex coordination of providers, services, and care falls short because providers may feel less sympathetic about the particular aspects of this disease. Some of our most vulnerable populations may have healthcare challenges that are frustrating or overwhelming to providers -- and it's important that providers are able to collaborate with social services and colleagues that can support these patients in ensuring appropriate care.
  • All good care goes beyond acute care. 
    It’s never enough to simply treat the acute illness that is right in front of us. But as providers, we need the tools and collaboration to care for patients more broadly than that. Most emergencies require more than simply treating the situation in front of us. A baby's stitches in the ER require follow-up with the pediatrician. An overdose necessitates counseling and substance abuse drugs.

Our EHRs and systems simply don't support this more broad understanding of what it means to provide care in complex situations. And that means our patients are receiving subpar care, due to the limitations of our tools and workflows. Each healthcare provider is doing his or her job to the best of his or her ability. But the demands of caring for our patients mean that sometimes just "doing our job" isn't good enough -- we must also look at the big picture of that care. And we must demand tools to help us act well and care appropriately within that big picture. 

 

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Tags: care coordination, healthcare collaboration

The 3 EMR Interoperability Blindspots Your Hospital Has

Posted by Lawrence Kerr on Thu, Feb 14, 2019 @ 06:00 AM

rawpixel-782046-unsplashRecently, seven major hospital systems put out a bold call.

It is crucial, they contend, to improve data sharing and interoperability among EMRs and EHRs. As Fierce Healthcare reports, "In a 2017 AHA survey, 57% of respondents had experienced challenges sending the proper information to a different vendor platform. And 37% ran into challenges just matching patient identities between systems."

Any healthcare provider who works with Electronic Medical Records won't dispute that data sharing is lacking with these tools. But despite the importance of this report, I see 3 crucial blindspots that it has -- and that your hospital may have, too.

I agree that interoperability among EMRs and EHRs is something that we should all demand. The simple access to data about your patient is as fundamental as having a clean and private exam room to see that patient in... or as having the ability to record your own notes about that patient. 

So I was glad to see this hospital report come out. That said, I believe there are three crucial shortcomings to this report. And identifying them isn't so much to undermine the findings or importance of the report itself -- but to identify blindspots that your hospital may have as it begins to pursue interoperability of EMRs and EHRs.

 

3 crucial shortcomings to focusing on EMR interoperability:

  • EMRs / EHRs will never be true healthcare collaboration tools.
    No matter how sophisticated interoperability among medical records becomes, the truth is that these systems will never be true healthcare collaboration tools. The records simply aren't made to easily facilitate multidirectional care coordination and medical collaboration among all members of a care team. And so it's a mistake to believe that by solving interoperability, we might have improved care coordination or collaboration. 
  • Providers need better tools now. 
    The reality is that even if EMRs and EHRs become more interoperable, healthcare providers need better communication and collaboration in the meantime. The reality is that today, EMRs and EHRs consistently get in the way of sharing data and patient information. Until the day that EMRs/EHRs are interoperable, healthcare providers must take the burden on themselves of making sure that other members of the care team have HIPPA-secure access to patient information. 
  • We need collaboration among people, not computers. 
    The AHA report emphasized that "there is an urgent need to coalesce around improved standards that overcome the significant gaps making communication difficult between systems." In other words: we need our computers to communicate better. But the harder truth is that allowing computer systems to share data is just Step One. What is really needed in medicine is the ability of providers to collaborate and coordinate care. The data-sharing is just the foundation -- it doesn't necessarily facilitate the profound collaboration that needs to occur for good care to happen. 

As always, these organization-level initiatives -- like those to improve interoperability -- are crucial. They are long-term projects that affect key foundational aspects of what we do as providers. But these projects are often uni-dimensional and may not affect our work in the holistic ways we need them to. So even as hospital-level and nation-level work occurs, we as providers must create and demand tools that are immediate and holistic enough to support excellent care for our patients. 

 

ClickCare Quick Guide to Medical Collaboration

 

 

Tags: care coordination, EHR, EMR, medical collaboration tool

Why Balls Get Dropped in Discharge to Skilled Nursing Facilities

Posted by Lawrence Kerr on Wed, Feb 06, 2019 @ 06:00 AM

 

hush-naidoo-1170845-unsplashThe United Hospital Fund is a nonprofit that is embarking on an important initiative. Their Difficult Decisions series explores the challenges that hospital staff personnel face in planning discharge.

The third in the series looks at the transition to post-acute care, usually to a Skilled Nursing Facility (SNF). And the study itself brought to light important insights for all providers, in understanding discharge planning, as well as patient transitions, more generally.

The most salient point in the study is, as Fierce Healthcare summarizes, that discharge planning presents profound obstacles for the hospital staff personnel who carry it out. Both administrators and staff very much have a goal of continuity of care. But the tools and structures that staff personnel encounter make the outcome of discharge planning fall short, many times. 

For any of us who work in hospitals every day, none of this comes as a surprise. That said, there were several nuances in the study that were enlightening in exploring when balls get dropped in discharge planning -- and how we might improve that process. 

Why Balls Get Dropped in Discharge to Skilled Nursing Facilities: 

  1. Discharge plans are made without real input from the people carrying them out. 
    One thing that I loved about this study is that it was carried out by talking directly to the people who are actually doing the work, in order to understand the real challenges and opportunities they face. For that reason, I think the insights carry more weight than a study solely based on administrators, or findings from a think tank or conference. Similarly, discharge plans are sometimes coordinated "at the top" rather than allowing them to be shaped and reshaped by the medical team, across the continuum of care.
  2. Discharge plans are often static. 
    The status of a particular patient changes quickly and often without warning, which means that the discharge plan must change and evolve, too. A static plan won’t work. And one that’s created once and then executed by members of the care team, in their offices or even across institutions won’t work. That’s why a tool like iClickCare -- which uses telemedicine to support medical collaboration for care coordination -- is so crucial. As the patient's situation changes, the entire care team can continue to influence the discharge plan, communicate about status changes, and get multiple perspectives.
  3. There is little communication across institutions. 
    Although, in theory, a nurse at a Skilled Nursing Facility, or a doctor at a hospital can always "pick up the phone,"  the pace of medicine and the realities of scheduling makes telephone tag nearly impossible to do successfully. For that reason, there is often little communicate across institutions -- for instance, from a hospital to a Skilled Nursing Facility, or vice versa. That means that information is often fractured and things can get missed, not to mention that crucial nuances of patient care fall by the wayside altogether. 
  4. Patients are given information, not guidance. 
    In theory, patients are given the information they need (for instance, a list of skilled nursing facilities). But realistically, they’re not being given the guidance or support necessary to make high-quality decisions about "next steps" in their care. True guidance and support means their whole care team working with the patient collaboratively -- throughout the duration of their illness.

In exploring the findings of this study, it was so clear to me that "trying harder" is not the answer when it comes to healthcare providers doing care coordination and discharge planning effectively. Teams need excellent tools and strong processes to support them in actually creating the continuity of care they intend to. And telemedicine-based medical collaboration is one of those crucial tools. 

 

You can try iClickCare today to support your organization in doing care coordination as effectively as it intends:

 

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Tags: care coordination, medical collaboration tool, skilled nursing facility, telehealth in skilled nursing facilities

A Surprisingly Simple Way to Improve Birth Outcomes

Posted by Lawrence Kerr on Tue, Jan 29, 2019 @ 06:00 AM

julie-johnson-692218-unsplashIn Sweden, 28% of women who give birth were born in another country.

These women may be Syrian refugees or arrivals from Africa, or France, or Spain. They speak countless languages and may not be familiar with the medical protocols and cultural norms of their new home. 

And this reality is not without its challenges. Sweden has good rates of maternal complications and mortality, but immigrants face outcomes six times worse than their native-born counterparts. 

That said, a simple new initiative has been changing that for immigrant women giving birth -- and the practice is rooted very much in medical collaboration and care coordination.

A recent article in the New York times explores Sweden's immigrant maternal health challenge -- in which foreign-born women face outcomes six times worse than Sweden-born women. Of course, these women may have significant linguistic and cultural barriers, keeping them from accessing the same standard of care.

Interestingly, the solution to this problem isn't intensive prenatal interventions or better technologies -- it's simply improving collaboration and communication.

This collaboration intervention comes in the form of "doula culture interpreters" -- trained women who assist a pregnant woman in her labor, supporting her in communicating with her midwife or doctor as well as helping her understand the norms and practices in the birthing process. These doulas translate from the immigrant’s home language and culture into their adopted language and culture. But they also translate the medical system, culture, and jargon. 

Sometimes the participation of the doula is as simple as literally translating from Swedish to, say, Arabic. Other times, the "translation" is from medical-speak to plain language. “Good communication is listed as one of the best ways to improve outcomes,” Dr. Esscher, a Swedish obstetrician, said in an interview. And, indeed, the doulas' support of good communication, has been having an effect on outcomes. 

I found this doula project inspiring in its simplicity. It's an intervention that doesn't involve displacing or dramatically changing any current practices or providers. It simply improves communication, collaboration, and coordination with the assistance of one of the doula interpreters. I also think that this kind of approach spotlights the importance of having collaboration tools that are flexible enough to involve multiple kinds of collaborators.

For instance, the old telemedicine paradigm of a one-to-one videoconference or text message thread between two doctors simply isn't enough to support this kind of approach. Rather, a truly team-based approach in which, perhaps, the doula interpreter, the obstetrician, and the midwife could all collaborate on postpartum or antenatal care, that is the approach that is truly necessary. Knowing this need generally, iClickCare has been structured to enable medical collaboration among multiple members of the care team, regardless of medical training, across the continuum of care. In an age when our care team includes a range of providers, offering a range of perspectives, this kind of tool is not only helpful, it's indispensable. 

To me, this program brings up questions that apply to all of us in medicine. First: We’re in a time where immigration and refugees are one of the challenges and opportunities that many countries face. How might we ensure that all people in our country experience the same quality of care and outcomes? And perhaps even more crucially: we're in a time when medical care is increasingly team-based, with a diversity of training levels and perspectives. How might we make sure that all members are engaged to provide the most coordinated, nuanced care possible?

 

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Tags: telemedicine solutions, care coordination, medical collaboration tool

Health Care Power-Users Point to Collaboration as Key to Care

Posted by Lawrence Kerr on Tue, Nov 06, 2018 @ 06:00 AM

rawpixel-577480-unsplash (1)

Frequently, “power users” of healthcare are seen negatively.

Whether because they are seen as more “demanding” patients or because of their relatively larger “burden” on the healthcare system, there is often a bias against these patients.

But a recent study — a collaboration among the New York Times, The Commonwealth Fund, and the Harvard TH Chan School of Public Health — looked in depth at these patients, both putting a spotlight on their behavior and experience, as well as sharing the wisdom they have about how to interact effectively with the healthcare system. Interestingly, much of what they shared advocated for a more collaborative, connective way of doing medicine.

In this study, “power users” of healthcare are defined as “people who have been hospitalized multiple times and are seeing multiple physicians, related to a serious illness, medical condition, injury, or disability.”

Of course, their perspective holds a lot of important insights for healthcare providers, for a few reasons. They: 

  • Have experienced more facets of the healthcare system. 
  • Necessarily developed skills and habits to deal with the shortcomings and strengths of the system. 
  • Are sicker and so may tax the system more, revealing faults that go less noticed otherwise. 

So this study of their experience, problems, and advice is enlightening. Among the findings: 

  • 30% say they were sent for duplicate tests by different healthcare providers.
  • 23% have had to wait too long for appointments, treatments, and tests.
  • Overall, they offer the following advice for navigating the medical system:
    • Show your doctor a list of medications you are taking (78%)
    • Bring a list of things to discuss with your doctor (70%)
    • Bring a family member, friend or someone else to all of your medical appointments to serve as a coordinator (55%)
    • Seek advice or help from a family member or friend who is a doctor, nurse or other health professional (34%)
    • Seek advice or help from a former patient who had a similar health condition (23%)

 

Our take on these results? People who use the medical system a lot experience the delays, confusion, and duplication caused by healthcare providers that aren't able to coordinate care or do healthcare collaboration. For that reason, the advice these patients offer tends to revolve around creating their own solutions to ensure care coordination on their behalf.  

Instead of patients trusting doctors and other providers to coordinate care, they do it themselves or involve friends or relatives to support them in doing it. This behavior certainly makes sense. And it's a wise way to approach a well-intentioned system that doesn't always work. But it does concern us, since patients have only a limited ability to truly coordinate care on their own behalf. For instance, a patient can bring a list of medications they are taking, but they can't bring a list of providers who should collaborate on a case. They can ask a friend to offer advice, but they can't necessarily facilitate meaningful conversations among all of the members of their care team. 

That's why we believe it's necessary for healthcare providers to have the tools they need to truly effect care coordination and healthcare collaboration. Sure, patients may fill in the gaps. But their ability to identify all of the possible gaps and truly fill them effectively is limited.

 

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Tags: care coordination, healthcare collaboration, medical collaboration tool

Why Overall Well-Being is as Important as Medical Intervention for Cost Savings

Posted by Lawrence Kerr on Tue, Oct 02, 2018 @ 06:00 AM

rawpixel-678092-unsplashHealthcare is such a potent combination of art, science, social work, and hard economics. And where these varying approaches touch each other, there can be friction.

So many healthcare providers view what they do as a combination of art, science, and social work — with hard economics never (or rarely) entering their mind.

But many times, healthcare economists come from a perspective that assumes something very different about how healthcare functions and how providers make decisions. Many times, healthcare economists use as a fundamental premise the idea that: providers are self-interested and will bill for as many services as they can; and it’s crucial to focus on hard outcomes of services, not on overall well-being of patients. Their perspective tends to be that hard economics reign and that these other approaches are dreamy intangibles.

A new study in JAMA challenges all of that.

JAMA published a study described as a “US national, population-based cross-sectional study [examining] the association between county well-being and Medicare fee-for-service (FFS) spending.”

In other words, researchers looked at whether Medicare spending was lower when people’s overall (non-medical) well-being was better. The results?  Medicare spent almost $1,000 less per patient for those in the 20% of well-being scores, compared to the bottom. And this is after adjusting for independent factors like income, urbanity, educational level, etc.

As the JAMA study explained, “Well-being is a positive state of being beyond the absence of disease, measured by not only physical health but also other dimensions, such as emotional, social, and economic health. Well-being may be modifiable by a broad range of interventions across different sectors.”  It’s all the stuff that we tend to see as “outside the scope” of a given medical intervention.

We think this is an incredibly important insight and study highlighting something not commonly spotlighted. Certainly, new models have gone up one level to reward fee-for-performance rather than fee-for-service. But the truth is that this measure of overall well-being is up several levels beyond that. And to capture the economic value of our patient's overall health and happiness is important. 

The whole goal of what we do as doctors is to support our patient’s well-being. But if you really needed another reason to pursue that measure, this is evidence that a broader view, a more holistic approach, is cost-effective too.

One of the challenges that we get into with iClickCare utilization is that it might be more efficient to just allow secure text-messaging, rather than having a fulsome, team-based, archivable healthcare collaboration system. The very reason we do what we do is because we believe that this kind of more holistic, team-based approach may not be the fastest way to get a simple, discrete answer — but it is the most efficient, effective, and cost-conscious way of approaching the whole patient. The "whole patient" includes all aspects of their medical condition as well as the other factors in their life that interrelate with that condition. 

The components of well-being in the study that decreased cost-per-patient so dramatically were largely non-medical. That means that any collaboration system that doesn’t allow non-medical caregivers and providers (social workers, teachers, caregivers, etc) to collaborate is misguided and ultimately wasteful in terms of ROI. 

We're glad that this kind of study is being done. And we continue to applaud the efforts of all of those healthcare providers who take the holistic view of their patient's well-being -- rather than simply addressing the malady in front of them. 

 

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Tags: medical collaboration, care coordination, healthcare collaboration

5 Reasons Bundled Payment Programs May Not Be a Silver Bullet

Posted by Lawrence Kerr on Thu, Sep 27, 2018 @ 06:00 AM

jordan-rowland-716475-unsplashMost healthcare providers let “innovations around reimbursement” come and go.

The majority of us — whether we’re aides, nurses, specialists, or generalists — try to provide the best care possible, in as reasonable a way as possible. And we let the reimbursement and payment fall however it does, after the fact.

That said, there are certainly big shifts that affect how we care for patients — and certainly how we’re paid to do so. And “bundled payments” are one of those shifts that are big enough to pay attention to.

A New York Times article did a thoughtful review recently of Medicare’s bundled payments programs. Currently, these programs are effectively pilots, with hospitals able to opt into the program, rather than making them mandatory.

As I’m sure you’re aware, bundled payment programs create a single payment for every health care service associated with an event. (Rather than paying for the healthcare services individually.) The idea, of course, is that this approach would decrease costs: “In theory, if doctors and hospitals get one payment encompassing all this, they will better coordinate their efforts to limit waste and keep costs down.”

Of course, anyone who has ever gotten a “meal deal” because it was a better value — even though they weren’t originally planing on buying chips or a drink — understands why this may not be the best idea.

That said, some data shows that at least for hip and knee replacements, overall costs are slightly lower than with fee-for-service models. But different types of healthcare are different. And data on hip and knee replacements may not relate at all to other areas of healthcare — especially when the data is coming entirely from hospitals who have opted into the program (rather than taking part in it mandatorily.

But we have some broader concerns about programs like bundled payments.

5 Reasons Bundled Payment Programs May Not Be a Silver Bullet:

  • Most waste isn’t coming from doctors pursuing profit over smart care.
    One core concept in the formulation of this type of program is that providers are seeking profit first and safe, considerate care second. My honest take? This happens, but not very often. And so it's possible that one of the framing ideas is false.
  • Savings from bundled payments necessitate collaboration — and collaboration needs tools.
    Bundled payments benefit greatly from collaboration that can be empowered by healthcare collaboration tools like iClickCare. But simply changing how things are paid for may not provide the tools necessary to make that collaboration -- and thus the savings -- possible.
  • Savings from bundled payments necessitate care coordination — and care coordination demands support.
    This type of integrated payment depends on the interdependency of the providers. As with healthcare collaboration, however, providers are often attempting to coordinate care against all odds. And so it may make more sense to make care coordination more effortless than simply to change payment structures.
  • The “bundle” might not be the right combination of services.
    The bundling structure assumes that it is known what’s needed for a given healthcare event. The reality?  Healthcare “events” can be unpredictable and complex -- every patient is different.
  • Savings are good but rationing usually isn’t.
    The author of the Times article makes a point about steering patient access. While it certainly makes sense to guide patients towards the most appropriate treatments, I worry that this structure can raise the spectre of rationing -- which usually means that people with the least resources end up getting the worst care. Plus, in these programs, quality is generally not taken into account, at least not in very sophisticated ways — especially tracking quality across different groups.

 

All of the above isn’t to say that an overall shift to value-based care isn’t desirable (plus, it’s likely inevitable.) But we do think that it’s important to advocate for supports for shifts in care and reimbursement — not just change how doctors are paid.

 

Looking for ways to save costs in your hospital system? Hybrid Store-and-Forward may be the simplest way towards great ROI: 

ClickCare Quick Guide to Hybrid Store-and-Forward

Tags: care coordination, healthcare collaboration, value based care

The Best Way to Help Young Patients? Get Them Back to Playing Faster

Posted by Lawrence Kerr on Thu, Sep 20, 2018 @ 06:00 AM

jelleke-vanooteghem-578746-unsplashAs you probably know, our cofounder is a pediatrician.

As someone who has treated children across socioeconomic groups for decades, she found that having a playhouse in the waiting room created a sense of normalcy, fun, and respect for the children she saw. She found that patients looked forward to their visits, since they could play in the playhouse -- and parents had a few unexpected moments of respite.

Of course, that was just one detail out of thousands as to how she cares for children in ways that are deeply effective and respectful of who they are as children -- but it highlights the ways that play are important in medicine.

Perhaps it’s eye-rollingly obvious, then, that the American Academy of Pediatrics would release a statement affirming the role of play in children’s lives. Perhaps their suggestion that doctors need to write a “prescription for play” is a good one.

But I also wonder whether, as healthcare providers, we should think less about prescribing play to parents who are already likely doing the best they can. And we should think more about how we, and the medical system, can get out of the way so that our patients can get back to play and learning.

Children have important work to do — learning and playing being two big parts of it. And one part of the tragedy of sickness — and the hospital stays, doctors' visits and long car rides that accompany it — is that children are removed from that important work of play. If play is so important, it’s crucial for our pediatric patients that we limit time in the hospital so they can spend more time “doing the work of childhood”

Sometimes the simplest solution is the most effective. In fact, I was reminded of this story of a terminally ill 2-year-old who loves Christmas. Realizing that he wasn't going to live until December 25th, his parents decided to recreate Christmas early that year. His neighbors, hearing the idea, decided to join suit. So the little boy's neighborhood became filled with lights, decorations, good cheer, gifts, and even a Christmas parade, even though it's only September. 

To me, allowing children to get back to play means different things in different situations -- sometimes a playhouse; sometimes a neighborhood teaming up for Christmas. But most of the time, in a medical setting, it means that we are doing care coordination and healthcare collaboration effectively enough that our young patients are spending less time in the doctor's office, waiting room, car-ride, and hospital. That means coordinating care so they can be released from the hospital 6 hours sooner. It means a team approach to care so that they're not bouncing from doctor's visit to doctor's visit with no resolution. It means using telemedicine to get a consult so that the child doesn't need to leave school to see yet another specialist. It means school-based health centers (linked to specialists by telemedicine) so that kids can get healthcare during the school day. 

Our view as providers must be broad enough to include an understanding of care that isn't simply about curing disease -- but about cultivating health in our patients (young and old). And that starts with getting patients back to their lives as quickly as possible. 

For stories of how medical collaboration can work in the real world, download our Quick Guide: 

ClickCare Quick Guide to Medical Collaboration

Tags: good medicine, care coordination, healthcare collaboration

Surprising Study Shows Doctor’s Race Crucial in Health Outcomes

Posted by Lawrence Kerr on Wed, Sep 12, 2018 @ 07:00 AM

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Black men have the lowest life expectancy of any ethnic group in the United States. Chronic disease — like diabetes and hypertension — play a big role. But the path to reducing rates of those maladies can seem unclear.

A new study by researchers in California showed a shocking finding in one parameter that could dramatically influence outcomes — the race of the doctor. 

The study itself was pretty simple and looked at the likelihood of patients to accept preventative measures, comparing the likelihood with a white doctor and with a black doctor. The study participants were 702 black men in Oakland, California, who came to a clinic for a free health screening. They were randomly assigned to a black male doctor or one who was white or Asian.

The results were pretty stark (as elucidated by The New York Times):

— 63 percent of the black men assigned to a black doctor agreed to a diabetes screening. Just 43 percent of those assigned to a doctor who was white or Asian consented to be screened.
— Some 62 percent of black men with a black doctor agreed to cholesterol tests, compared to 36 percent assigned to a doctor who was not black.

These rates might not sound world-changing, but the consequences of them are. If black patients were to agree to preventive care at these rates in the real world, researchers estimate that the gap in cardiovascular mortality between black men and the rest of the population could be reduced by 20 percent.

So was it the race of the provider itself that made the difference? Or was it something that black doctors were doing differently, or more effectively, than the white doctors?

There’s no hard evidence to answer that question, but one telling component of the findings are the comments written by both patients and doctors in the study. Black patients had equally positive comments of doctors, regardless of their race. But of black doctors, their comments skewed more emotional and effusive. Similarly, the notes on  the white doctors tended to be shorter and dryer. Black doctors’ notes were more detailed and more holistic, including comments on elements of the patient’s experience and overall life.

One of the black doctors in the study really affirmed that ultimately, it’s not about race — it’s about good care. “It’s something they don’t teach you in medical school — taking that extra step because you appreciate there have been barriers in the past,” Dr. ChaRandle Jordan said, saying that white doctors can reach out just as well and that a lot depends on how familiar a doctor is with black patients.

From our perspective, there are several key implications of this study for our work with medical collaboration and care coordination:

— A team approach is important. Sometimes the background of the provider can make a difference, and where that's true, having a diverse team working together closely, is a key asset. 

— Good care is about more than the facts. Simply offering the appropriate preventative screening isn't enough. In this study, it appears that the black doctors' efforts to build rapport and even to push back on patients' initial reticence were a big part of their good outcomes. Having the perspective and tools to work with a more holistic sense of the patient is key.

Obviously, we believe that great care can happen among providers and patients of any race. But looking at race and differences in engagement and interaction shouldn't be taboo. We often say that "no one of us is a smart as all of us."  And this is one more example of how our colleagues down the hall may have a lot to teach us — if we are open to learning. 

For stories of medical collaboration, download our Quick Guide: 

ClickCare Quick Guide to Medical Collaboration

Tags: medical collaboration, good medicine, care coordination

Is Medicine Today Shift Work, Team Work, or Solo Work?

Posted by Lawrence Kerr on Thu, Aug 23, 2018 @ 06:00 AM

john-price-380340-unsplashIt’s increasingly rare in everyday life to have someone take responsibility for caring for you or serving you.

If you sign up for a new account at a bank, the smiling salesman doesn’t end up being the person you interact with when you stop in to make a deposit. Most of us no longer have personal relationships with our grocers or butchers or farmers.

And the field where this change seems the most dramatic is medicine. As we’ve all experienced, the last few decades have shown a shift in medicine from everyone having a family doctor to… almost the opposite of that. Hour caps for residents, the rise of hospitalists, an emphasis on advanced practice nurses, and a change from medicine-as-a-calling to medicine-as-a-career-path have all contributed to a more fragmented, less personal relationship between patient and doctor.

So do these changes mean that medicine is now shift work?  And are the outcomes of these changes negative across the board?

As a surgeon, I always believed that the person who does the surgery is the person who checks on the patient after surgery. In my life, that sometimes meant my kids waiting in the hallway while I checked on a patient right on the way to a restaurant for Saturday night spaghetti. The generation before me might have done house calls and likely knew whole families, over generations.

A recent New York Times article looks at the shifts that have occurred recently.  These shifts have pushed medicine dramatically away from each person “having their doctor” to care being provided in a way that’s agnostic of who is giving the care and is more about who is responsible during any given hour, or for any given problem. The interaction described by the doctor and author of the article is emblematic of precisely these changes:

“Will you be my regular doctor?” a new patient seeing me in my primary care clinic asked.

“Sort of,” I honestly answered.

She looked back at me quizzically.

“Technically speaking I will be your doctor,” I explained. “But you may have trouble scheduling an appointment with me and may have to see another doctor here at our group clinic at times. And if you need to get admitted to this hospital, other doctors who work there will take care of you.”

 

Although I think that this change is positive in many ways -- and ultimately necessary -- I also worry about some of the "side effects" of the shift to shift work.

Specifically, I think that there are a few specific negative consequences of the change from medicine being a calling, with ultimate personal responsibility, to medicine being a career path, made up of people primarily doing a kind of shift work:

  • Lower satisfaction for healthcare providers. If you're handing off patients to a colleague once you complete your shift or role in care, you don't see the "welcome home party", hear about the happy return to a hobby, or see the relief in a daughter's eyes. Frequent handoffs in medicine often make it less satisfying to doctors because you don’t see the real life outcomes of your patients.
  • Less holistic care. The more we know about our patients' lives, families, circumstances, goals, and passions, the more we can make their care smart and holistic. The more fragmented care becomes, the less holistic it becomes -- the third provider in the handoff chain may have no idea about a key personal circumstance that could affect care or compliance.
  • More coordination mistakes. More handoffs mean more cracks for things to fall between. So often, signing out to a colleague is the crucial link in the chain to avoid problems -- but this step doesn't always or can't always happen.
  • Decreased trust in healthcare system. I've noticed that one reason patients trust medicine, and doctors specifically, less than they used to is that there isn't any one person to trust. 

So is good care possible within this fragmented system? I think it is -- but it involves a key shift in perspective. And I believe that the shift in perspective is this: 

We must evolve from shift work to team work. 

We can't go back to the old model of medicine as solo work. It looks like, for most of the population, we're not going back to house calls or family doctors. But even within the current medical framework, we can change from a handoff mentality, to a team mentality – we can evolve from shift work to team work. On a team, each of us is not always carrying the ball or responsible for the patient. But we're all always responsible for the outcome as a whole. That means that as medicine has changed, healthcare collaboration and care coordination has become not a "nice to have" but an absolute "must have" in order to provide adequate care to our patients. Ultimately, team work is about taking responsibility for the outcome of every single person we care for, even if we collaborate with colleagues on portions of that care.

It's not about handoffs, it's about collaboration. 

 

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Tags: medical collaboration, care coordination, healthcare collaboration

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