Docnotes

Health Protection and the role of HIT

Health Affairs arrived in the the mail today.  

I pulled it open like an excited kid opening a birthday gift.  Despite my affection for all-things-digital, there is something to be said for propping my feet up on the coffee table and reading insightful work on important subjects.

This paper describes a compelling story that I'll try to paraphrase - as it introduces the concept of PROTECTION that  I'd not previously considered.

The authors consider three possible interventions to improve the health status of a population:

• Coverage (increasing the scope of insurance coverage)
• Care (facilitating providers and patients to follow best practices for preventive and chronic care)
• Protection (enabling healthier behavior and safer environments)

The paper describes the results of a modeling exercise in which a population receives one, two or all of these interventions.  The results predict that expanding coverage would result in modest improvements in health status and cost, Coverage PLUS Care results in better health status and reduced cost - and (after a 3 - 5 window of increased cost) Coverage + Care + Protection results in MUCH better overall health status and reduced cost.

So what?  This study reminds us that:

a) Expanded coverage is not the only answer.  In countries with universal coverage - we see good validation of this unfortunate reality.

b) Better care is also a necessary but incomplete solution.  

c) The hardest part - and likely most essential - is that we need a cultural shift in how we can create and maintain a healthy environment.  

How do we get there from here?  

My intuition is that we treat the nation (globe) as we would an addict.  We have become addicted to certain behaviors that we know to be destructive.   Yet we continue.  Smoking, obesity, lack of exercise, over-eating ... these are all key components of our addicted nation.

Years ago, I became impressed with the work of William Miller, Marian Stuart,  and James Prochaska - and used their techniques successfully in my practice.   The common thread is that we understand and support our patient's interest in following a path toward better health.  This is terribly hard to do in a manner that isn't judgmental.    But when we judge ("this is bad behavior") we alienate the patient - and make collaboration more difficult.  It is only when we are open to the outcome - but not focused on one outcome in particluat - that we collaborate toward success.

So when the patient is a globe or a nation or a community - how might we mive forward?

a) Recognize and reflect.  "Is this how you want to be living?  Is there anything you would like to be different?"

b) Celebrate Success.  "How have you been successful in the past?  What might you try again in the future?"

c) Offer tools and support.  Reminders, suggestions for alternatives, skill-building.

I often notice that many communities have built such traditions that they don't even know how to behave differently.  

In our industry - HIT - I think that be most productive use of our time is to focus on (c) - so that we can help providers and patients collaborate (a) and (b).  

e-Communication with patients

Readers have started asking me about my new company ... 

Perhaps the change to my LinkedIn profile was the tip-off  :-)

While we're not quite ready to publicly describe what we're doing, I CAN say that our focus is on creating great tools that providers and patients can use to communicate.

While e-communication has become pervasive globally - it has not become part of the routine in healthcare. I met with a colleague for lunch last week - and she described the pile of paper faxes and letters she receives daily from other physicians. She communicates with patients using e-mail "only rarely - for a small number of patients" and even limits phone calls as much as possible - delegating them to a nurse.

A face-to-face visit in the office remains a cornerstone of communication between patients and providers, and the fax machine remains the preferred route of communication between primary care provider and specialist.

Will this change? Of course it will. That's the bet we're making - and I don't think that it's a scary bet at all. e-communication between patients and providers is better, and it doesn't take longer.  Provider satisfaction improves, patient satisfaction improves.  Everyone is happy.  Right?

Well .. no.

The key barrier here is ... money.  HIMSS did a survey and found that lack of reimbursment was the key barrier.

Doug Fridsma (Long before be went to ONC) did a study way back in 1994 and found different barriers and a remarkably high level of use.   Back in 1994 - it seemed like we were on the threshold of an explosion of e-communication.  Why didn't it happen?

a) Insufficient financial incentives.  Yes - I believe that lack of reimbursement is a key barrier.  In places where this is part of a provider's job - the use of e-communication is pervasive.

b) The tools stink.  I'm tempted to use a stronger word - but I won't.   AOL (You've Got Mail!) didn't evolve into Facebook.  AOL (and others) have been disrupted by Facebook.  The existing software for this sort of communication was built long ago - and it simply didn't anticipate the needs of 2011.  You can't build a skyscraper on the foundation of a four bedroom colonial.  The current tools will not survive.

c) Timing.  With the exploding interest in mHealth, and the ubiquity of communication devices - we now have methods of connecting that weren't imaginable ten years ago.  As PCMH experiments such as those at Group Health Cooperative and others demonstrate - it's BETTER CARE to keep patients out of the office and out of the ER.  One way to do this is to increase our availability.  With much more data available - we should expect to see more payers experimenting with reimbursement models that are inclusive of e-communication.  Is this a PCMH pilot?  An ECO experiment?  We'll have to see.

So at Twistle - we're honing in on what we think will be the best software solution to help solve these real problems.   I've launched a 30 second survey to help us understand which specialties might have the most interest in using a new solution today - even without reimbursement changes.

Since I'm a family physician - I think with my "primary care" hat on by default.  This isn't good.  I need to try to pretend to be a specialist sometimes.  So I schedule myself to spend time with other physicians on a regular basis so that I can better understand them.   As this study demonstrates,  in 2008,  there are interesting patterns:   21% of female physicians e-mail with their patients vs 19% of men.  19% of primary care;  24% of specialists.  28% of those in a multispecialty group vs 17% in a single specialty group.

Why would a specialist be more likely to e-mail her patients than a primary care physician?  One answer we're hearing a lot is "opportunity cost."  Even though the providers aren't paid for the e-communication - a specialist's opportunity cost (especially a busy procedure-centric specialty) is significantly higher than that of a primary care physician.  So if a busy gastroenterologist can e-mail with six patients in 20 minutes - and keep those six patients out of the office - then she has time to do one more colonoscopy!

This differs from the attitude of my family physician friend - who feels that she needs the face-to-face visit for all conversations - as she fears that e-mail would otherwise consume her day - without any reimbursement.

Much more to think about here.  Please do take the survey and pass the link along to your friends & colleagues so we can get some good data.  I'll share the results here in a week or so.