The authors state, rightly so, that we cannot possible keep up or engage with the sheer volume and flux of [healthcare] knowledge occurring today.
NPRs Planet Money has a podcast this week titled ‘How Do You Decide Who Gets Lungs?’ It was an excellent examination of the current system for organ donation and recent changes to that system. An interesting point was made. Pre 2002 liver transplant lists were set by patients in ICU and time in ICU. Those in ICU were at the top and the longer you were in the higher your position on the list. Post 2002 it was changed to a more objective criteria including bilirubin, creatine levels among other clinical data. During the discussion physicians said that once the system changed the number of patients in ICU needing a liver transplant dropped significantly. They admitted that that may indicate gaming of the system. doh? In the new system it is harder to game it since the criteria is clinical and objective.
Overall this was an excellent podcast on a very critical topic in healthcare. But I feel they missed a point. Transplantation is a huge business for both the institution and the HCP. There is an economic incentive to get the organ in order to do a transplant. I am in no way saying institutions or HCP position economics over patient care. What I am saying is that Planet Money may have missed another point to examine, what are the economics of transplants? But that is not as dramatic as life and death.
In my estimation a goal beyond the clinical exam of an office visit is to have both the HCP and the patient establish a foundation for better outcomes by managing knowledge and sharing problem solving. In a sense this is a form of shared decision making (SDM) where HCP and patients communicate thus moving the relationship from paternalism to partnership. SDM is labor intensive and best suited to chronic or terminal illnesses. How can the busy PCP change a HC transaction to a learning experience and gain the benefits of SDM?
All practices comprise patients at varying degrees of health status and age. Each segment will reside on a different part of the learning continuum. Say 10 is a highly active involved learner and 1 is a non-learner. The reality is that we can’t expect to move all patients to a 10. The goal is to move patients to be more active in their HC involvement. Say a 2 to a 4 or a 5 to a 6. These small changes can make a difference.
Over the course of six months each patient visit should be accompanied with a short questionnaire to determine where patients reside on the learning continuum.
1. Do you have a chronic illness or a healthcare problem that you are concerned about? Y/N
2. Are you actively learning about your illness or problem? Y/N
3. If you are active in learning what are your sources? (RankInternet
- Social media and groups with similar concerns or illnesses
- Friends and family
- Medical and scientific journals
- Support groups
- Healthcare professionals
4. If you have a chronic illness or a healthcare problem but are not actively learning about your illness why?
- My HCP is my decision maker
- I know a lot about it and am managing it well with my HCP
- I don’t have the time or desire to pursue this type of information
- I never considered learning more
5. If your health is good and you have no HC problems are you interested in learning more about your health? Y/N
These five simple questions will first open an entry point for discussion. The HCP can identify what problems the patient is seeking to solve, are they active learners, where do they learn, etc. The key for moving the office visit from a drive by transaction to a learning experience is knowing where the learner resides and if they want to learn.
The data can be put into a database by disease, interest in learning, and other patient demographics. Once this is completed an educational strategy can be identified by segment or group. Outcomes can be as simple as did the patient at the next visit change his or her opinion about learning? Did they add some new knowledge to their knowledge base? Bottom line: the HCP should be the primary resource for patient learning or the most trusted. With a small effort the HCP can control and manage this knowledge channel
Prime Burger on 5 East 51st across from Staint Patrick’s is closing after 74 years. My first non-sales job was in the building around the corner on Madison Ave. I was doing medical advertising. It was just down the street from DDB. (Those famous VW ads). It was amazing to be in advertising in the heart of mid town surrounded by ad agencies and everything we see on Mad Men. It was where I met Donna.
Prime Burger had the best EVER burgers and fries perfect just perfect. Life is organic it lives and dies one big cycle. This article reminded me of what has been in my life not what is gone.
The NEJM published ‘Emergency Departments, Medicaid Costs, and Access to Primary Care-Understanding the Link’. The article examined Washington State’s Health Care Authority effort to curb non-emergency care delivered in ED. ‘By July 1, hospitals accounting for at least 75% of ED utilization by Medicaid fee-for-service clients must submit legal attestations that they are complying with the plan. If they fail to do so, the Authority may proceed with implementing its policy of nonpayment for ED visits it determines to be nonemergency visits.’
We all know to well the reasons, since 2008 9.8 million Americans have lost employer-sponsored health insurance. Subsequently Medicaid rolls have burgeoned by 7.5 million. States are looking for ways to cut spending on Medicaid and the low hanging fruit is overuse of EDs.
A 1996 study researchers posted in 56 ED nationwide interviewed 6,187 walk-in patients in a 24 hour period. The majority cited clinical reasons or preferences, while 45% identified a medical emergency and finally 19% said they sent by an HCP.
Will this type of action help Medicaid beneficiaries to not seek nonemergency ED visits and hit the primary care physicians office? Two well made points: most ill patients can’t differentiate a sprain from a break and 3% to 5% patients identified as nonurgent at the ED by a trained triage nurse needed immediate hospitalization.
For the low income Americans the ED is the only reasonable choice. If they are turned away because of state policies we may be facing a larger crisis of critically ill patients needing greater care at greater cost. The primary care physician is key here. But it is not the only part that needs to be changed.
This is a complex system of patients, ED, primary care physicians, nurses, and state government all looking at aspects of this issue differently. Trying to change behavior one audience or system at a time with brochures, letters, email, etc. will largely go unnoticed because as you shore of one part of the system the other falters. Healthcare whack a mole.
This is the perfect example of where Knowledge Translation can bring behavioral change on a large scale.
Knowledge Translation is defined as:
“the exchange, synthesis, and ethically-sound application of knowledge—within a complex set of interactions among researchers and users—to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system (CIHR, 2004).”
Knowledge Translation is the coordination and active manipulation of new knowledge (e.g how to teach patients to not rely on the ED) and it application to all parts of the system through prior research. KT relies on process improvement within these complex systems, not simply a laying of pamphlets on learners. Or forced economic changes. It is a system wide approach.
In my estimation we need to step beyond Draconian responses to a single aspect of a problem (i.e. overuse of the ED) and look at the entire system. Attack it as a systemic problem including fixing the primary care mess in America. I have not seen a better example of where KT can be applied to change behavior.
Digital Tonto’s fourth paradigm shift is ‘From Transactions to Experiences’. This captures the essences of the three previous shifts and I believe has the greatest application in healthcare.
Greg states, previously the brand and the consumer had a one-time value exchange based on feature benefit attributes. Consumers expected x and received x. This mimics the brand (physician) and consumer (patient) historically and in many instances today. The physician offers a value: care and management of your health on an as needed basis. The features are apparent, knowledge, expertise, experience, prescription, etc. The benefits are equally apparent, wellness. It was a simple value exchange. I need a checkup, I saw my HCP, I had a cold, I saw my HCP, I have a chronic illness, I see my HCP. In between these moments of interaction with my HCP there is healthcare inactivity unless there is chronic or terminal illness. Or I am one of the growing numbers of patients who are going online or engaging in social media to improve my healthcare knowledge. Largely this occurs outside the office visit.
The simple value exchange is morphing before our eyes. Brands are partnering with consumers in order to achieve ‘maximum utility and enjoyment from their purchase’. Brands want to create experiences for consumers. Remember, adult learners and all adults learn from experiences and upon reflection adults will integrate experiences into their lives.
As I’ve stated previously the office visit is not a drive by. It can be the place to begin life long learning. Physicians must engage in life long learning. It seems simple to have patients do the same? There are a huge number of patients engaging in learning about their own a loved ones healthcare. It is where, with little work, a HCP and patient can maximize the effect of simple check-up to the management of chronic illness. The smallest functional environment of learning in healthcare is the patient physician office visit. It does not have to end there. Both physician and patient can change that transaction to an experience and create a learning narrative. Make it a learning experience for both parties.
I will present ways to begin this healthcare learning experience in future posts.
Is this the lasting impression America has on pain management: it’s a criminal conspiracy?
And those who should know how to treat pain don’t do it very well.
I would say we are trying to look taller fighting pain medication drug abuse by standing on the terminally ill. Somehow we need to find a way to do both AND not do one at the expense of the other.
In Digital Tonto’s post ‘4 New Marketing Paradigms’ Greg’s second paradigm is titled ‘From Campaigns to Platforms’. http://tiny.cc/srj2dw His premise is that marketers can no longer just run ads till they wear out; they need to build campaigns that integrate social media, e-commerce, and interaction with the reader/viewer. Marketers are now ‘tailoring the message to past behavior’. I am very found of his closing sentence ‘Brands need to become authors whose stories unfold over time.’ www.digitaltonto.com The brand becomes the connection to reader/viewer not just a feature or benefit.
How does this relate to healthcare? The physician is the brand. The patient is the consumer of that brand. The office visit for a check-up or care for an acute or chronic condition is the ad/commercial. It is where the consumer (patient) interacts with the brand (physician). And historically it is a flat moment where the patient is passive and the physician active. With all the changes occurring in healthcare etc. more patients are becoming active in their health and care. Many physicians are stepping up to meet that half way. But that is not enough and it misses key inflection points. Engagement between physician and patient is becoming the new black and it is up to the physician to lead the way. To in a sense create that learning narrative with the patient.
The physician as a brand should look at that visit not as a one time event in a string of events. It is a way to build a brand platform based on patient needs and goals. It is the moment where the physician can determine not just blood pressure but pressure points for knowledge uptake and begin that healthcare narrative. What are the problems/goals/needs the patient wants? How can the physician become the author of a patient narrative? Does the patient leave with an Rx? Or do they leave with a continuum of care based on integration into the brand platform? ‘My physician is a great doctor but he is also doing more then caring for me, he hears me.’
Yes, yes I know, not all patients want to be part of a platform or need to be. The 20 year old patient in excellent health who comes in for a check up is not looking to solve a healthcare problem. And frankly many older patients with chronic HTN are not interested either. What exists is the opportunity to for HCP to take the pulse of each patients’ needs and goals regarding their health and learning styles and to change the office visit from a drive by to an engagement for life. Why can’t patients move from grade school to graduate school in their relationship with their physician over time? Physicians need life long learning. So do patients. I’m getting all misty here http://tiny.cc/93j2dw
And yes dear readers (all three) you re correct, how does a busy HCP achieve this? Stick with me and it shall be shown.