Reimagining Primary Care

What we will discuss today• Brief outline of the current ills of the system

• Disruptive Innovation model of Clayton Christensen

• Description of my practice as a step towards a new system

• The outlines of new system - Prosumer Health and the co-production model

William Butler Yeats

“And what rough beast, it’s time come round at last, slouches toward Bethlehem waiting to

be born.”

What has the current system gotten us

• Excessive cost and waste - heading to 20% GNP; 30-50 cents of every workers compensation dollar

• High rates of error and and missed diagnosis - 3rd leading cause of death

• Lack of access - especially in rural areas

• Provider/staff burnout - >50% in many studies

• Looming shortage of primary care providers - again focused in rural areas

• Costly, inappropriate use of laboratory and imaging studies - recent Canadian study

“Knowing what you know now, would you keep doing what you are doing? If the answer is no,

stop!” Peter Drucker or

“if you keep doing what you always did, you will keep getting what you always got!”

“All models are wrong, but some are more useful than others” George Box

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The Christensen Model of Disruptive Change -“The Innovators Prescription”

• Technologic enabler - simplifies and routinizes previously expensive, complex products

• Business model innovation - delivers solutions that are more convenient and cheaper

• Value network - commercial infrastructure whose constituent companies have consistently disruptive, reinforcing economic models

Medical Processes

Intuitive medicine -> Empirical medicine -> Precision medicine

Intuitive Medicine precise diagnosis not possible; highly

trained specialists needed

Empirical Medicine

data show that certain ways of treating patients are statistically better

Precision Medicine

Diseases well enough defined that treatment can be standardized

Organization of Care

Solution shops ->Value adding processes -> Facilitated Networks

Solution Shops

Structured to diagnose and solved difficult problem. Groups of specialists

Value-Adding Process Businesses

Take incomplete or broken things and transform them into something of value e.g. Minute Clinic; free standing

endoscopy clinics

Facilitated Networks

Enterprises in which people exchange things among one another e.g. Peer to Peer networks; group visits for chronic

disease

The General Hospital Problem

• They have all three business models under one roof creating significant inefficiencies

• Current response - consolidate and get bigger

A look at my practice as a step toward a new system through the lens of:

• Principles

• Leadership

• Tools

• Employees

Principles - “self evident, self validating laws that govern our behavior - provide the why”

• Standardized use of the Problem Oriented System

• Follow Quality Management (TQM) System of management

• Standardization with flexibility - Problem Knowledge Couplers

• Allow all staff to participate in all phases of medical action where competence can be demonstrated by performance audit

• Utilize the principles of Highly Reliable Organizations

LEADERSHIP

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Problems with Physicians as Leaders

• Insufficiently trained to operate in new disaggregated systems - dispersed teams

• Need for excessive control - hard giving up functions

• Sense of entitlement

• Victims of medical malpractice

“A LEADER IS BEST when people barely know he/she exists, not so good when they praise and obey him/her, worse yet when they despise him/her. But of the wise leader, when the work is done and the goals achieved, they

will say we did it ourselves.” Servant Leadership; Earned Authority

Servant Leadership, Earned Authority

Tools

Why Tools

“Man is a tool using animal. Nowhere do you find him without tools. Without tools he is nothing; with

them he is everything.” Thomas Carlyle

“Ryan is a slow adopter”

Why we are “predictably irrational” - unconscious bias’s influencing our

decisions

• Confirmation bias - making an immediate judgement and ignoring information negating that decision

• Anchoring bias - tendency to select options for which the probability is known rather those for which it is unknown

• Availability bias - the last diagnosis for of a problem increases our tendency to pull that up again first

• Base rate neglect - failure to incorporate the true prevalence of a disease into diagnostic reasoning

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Oh yes, not to mention -• Fatigue

• Interruptions

• Missing information in the record

• Emotional upset

• Inadequate time

• Information overload

• Inability to keep abreast with medical literature

Clinical Decision Support Tools

Problem Knowledge Couplers - stop trying to be an “intellectual John Henry.”

Goal: make quality the constant a time the variable

• Computerized clinical decision tools

• Clinical knowledge continuously updated

• Standardized inputs - not left to the idiosyncratic minds of providers

• Encompass both diagnosis and management

• Provider and patient presented with array of options and a path for sorting them out

• Raises the level of function of everyone - PSR, Medical Assistants, Nurses, Nurse Practitioners and Physicians

Does CDS Work?• Recent studies at UCLA showed machine learning applied

to EMRS in pediatric clinic equaled skilled pediatricians

• Triage experience in my practice

• AI reading retinal photographs; mammograms

• Medical assistants using AkeLex system described below able to handle 75% patient complaints

• Rosalind Franklin University of Medicine and Science -PA students using CDS achieved better results on diagnosis than obtained discussing with preceptors

People/Employees

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What Motivates Knowledge Workers? Daniel Pink. “Drive” Riverbed Books 2009

• Autonomy - control over their work lives

• Self Mastery

• Higher purpose

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Selection/Training • Hire character and teach the skills

• Core of behavior - thoroughness, reliability, efficiency and analytic sense

• Training - skill and performances based

• Cross training (internal redundancy & resilience)

• Coaching model - speed to proficiency

• Challenges to scope of practice - education vs skill

• The daily dance of “self-organization”

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Principles For a New System• Put the patient at the center of care and have them assume as much responsibility for

managing their care and reducing medical dependency as much as possible.

• Move care out of the office and to the patient at a place and time convenient to them - the cost to a patient of an office visit is around $43

• Inputs to solving or managing medical problems should be standardized and based on the latest medical knowledge.

• Create standardized rules for the management of medical information like the GAAP rules for accounting

• Use modern information tools to bring all patient information to bear on each medical problem creating care plans unique to that individual.

• Roles should be skill and performance based and not necessarily levels of education. Audit of performance should be based on the behavioral characteristics of thoroughness, reliability, efficiency, and analytic sense.

Prosumer Health

“Upon this gifted age, in its dark hour, rains from the sky a meteoric shower of facts…..they lie unquestioned,

uncombined. Wisdom enough to leach us of our ills is daily spun but there exists no loom to weave then into a

fabric.” Edna St Vincent Millay

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Co-production of Care Model Gene Nelson & Paul Batalden

Professors Community & Family Medicine The Dartmouth Institute for Health Policy and Clinical Practice

• Manufacturing vs Service production

• Customers as obligate coproducers of service outcome

• Health coaches as professional collaborating with patients to help them find their own best way

• Patients able to enter data outside of office visits

• Creating a Learning System - strong commitment to collective learning

Do Health Coaches Get Results? Diabetes Study Joslin Clinic

• Care of chronic disease consumes 70% of health Care budget

• Nationally - 29 million diabetics, 59% uncontrolled at a cost of 245 billion dollars

• Standard care (visits to MD office) —> 1% reduction HgbA1c —> $9,949 total cost care

• Standard care + Health Coaches doing virtual visits, text message, standard protocols —> 3.2% reduction HgbA1c —> $6,017 total cost care

Co-production Model Results

• Inflammatory Bowel Disease in US - steroid free remissions Improve from 55% to 78%

• Patients with rheumatoid arthritis in the Netherlands showed 50% reduction in inflammation

“It ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a

new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the

new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the

incredulity of men, who do not readily believe in new things until they have had a long experience of them.”

― Niccolò Machiavelli, The Prince