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Its Time for an Integrated Disruption of Transitions in Care!

May 30, 2017 / Darren Larsen / 18 Comments

Last month I wrote about Transitions in Care from the lens of quality, published in early April both here and in HQO’s QI Forum called Quorum. The article described what prevents transitions from happening smoothly, and highlighted some solutions, both technical and non, that have made hand-overs somewhat easier.

Yet, as a family doctor, I struggle with the need for more. Problematic transitions are largely a human issue, not one that is completely solved by technology. They are poorly integrated and rarely serve either the patient or their provider. It might help to explain the experience of a family doctor or primary care nurse in this case, describing what it’s like moving people between different healthcare silos when all we want is the right thing to happen for their care.

So what is a suitable analogy for how it feels moving a patient from my clinical care to another part of the health care system?

It is much like the experience of a parent who is trying to get one of his teenaged kids to basketball practice. In this scenario, as a family physician, I am the parent. My patient is the teen. If I am not able to drive her to the practice myself, one option would be to call a taxi to get her to her destination. Here, the taxi is a proxy for any moving part of the health care system, from a referral to another provider, to obtaining homecare service access, to getting a patient into hospital for surgery.

When I put my child into a taxi I want her to arrive safely and without incident, and there is a certain level of trust that she will. Thankfully, usually this is the case. But this trust comes without knowing virtually anything about the journey. The route is undefined. The taxi may take highways or poorly marked back roads. There is no easy way to track where it has been or is going. There is a vague confidence that the driver is probably competent, but really I have no insight into his safety record, driving skills or even how clean his car is. My child climbs in and we say goodbye knowing that almost certainly she will be fine, but still there is a background level of uneasiness and worry about the journey until I am aware that she has arrived in one piece.

Recently, though, a revolution has happened in the taxi industry. It has undergone a disruptive transformation and changed dramatically over the past five years. It has been revolutionized by Uber.

In healthcare, our discomfort with transitions must change. We have to disrupt the process.

Putting my child into an Uber sedan en-route to her destination is very similar to a medical hand-off. With either a taxi or Uber, a relative stranger is being entrusted with my daughter’s care. She will likely get to her destination either way, but in the “Uberfied” world this happens with much more transparency. I make a single simple request for service in a very convenient way, launching the request from a tool with which I run most of my life. (With Uber this is my phone, in medicine this is my EMR.) When I request service I know the license plate number and type of vehicle it is attached to and even something about the driver. There is a picture of him and a rating of his service from previous riders. If I am not confident in him I can even choose another driver. By having access to this information I have begun to build an implicit trust and there is the beginning of a social contract. Also, along the journey, I have line of sight to how long it will be before the car arrives, and after it leaves I can see where my child is on her route. I am even alerted as to when she arrives safely, and if there are any worries or concerns I can text or call the driver at any time.

When comparing the taxi and Uber scenario, it is interesting to note that at times it is even the same driver and same car being used by both services.

So what is different? It’s the integrated process.

In an integrated and well managed system of transitions, as a physician I would have access to knowledge about the journey, the vehicle and the driver. There would be excellent communication between all the people who are touching my patient. This would have a personal feel and sense of connection. The drivers/health care workers I interact
with would feel proud of their work, and be accountable to our shared patient with the hope of being highly rated. There would be a single step to ordering, contracting, handing off, tracking and rating the service, both by the patient and the physician. The patient would be the centre of the transaction, trusting the process from start to finish. He would feel comfortable integrated into a strong and dynamic network.

So what does primary care need to improve the experience of navigating and advocating for our patients? What would integration look like?

We need to be able to trust that our patient was handed off warmly from place to place or person to person
We must have reliable, trackable and dependable service delivery
There should be a sense of what, when and where care is happening and by whom
There would be seamless connectivity and communications between all providers
Trust would be both implicit and explicit, knowing that others value the relationship they have with my patient as much as I do
We would hold the system, providers, ourselves and our patients appropriately accountable for their aspects of the journey
Data to drive information, knowledge and insight would be in real time and available when/where it is needed at the point of care
The entire set of transactions would be based on the best interests of improving our patient’s condition, not accepting “buffing and turfing” or “passing the buck” onto the next provider to absolve our responsibility
Patients would be empowered with their own data to help steer the ship as they are the ones most involved in their care for the 99.9% of the time we are not with them
Systems and policies would be in place that maintain and enhance relationships, not disrupt them. And all relationships in an integrated team would be valued.

image source: gapingvoid.com

This is not simple work. But it’s important to me as a family physician. We must ask ourselves how the health care system could be more disruptive in creating transitions to ensure that not a single person falls between the cracks. Modernization of integrated transitions in care is no longer an option. It is mandatory, and we should settle for nothing less.

Why are Transitions in Care so Difficult?

** This article was originally posted April 3, 2017 on HQO’s new Quality Forum called “Quorum“. This is an online community for those interested in and doing quality improvement work in Ontario healthcare every day!

For patients, caregivers and providers alike, a transition in care is often a frustrating experience. When looking at why, many problems are uncovered. A transition occurs when care is handed off from one environment to another (i.e.: hospital to home), one person to another (i.e.: specialist to primary care) or one program to another (i.e.addiction support to general mental health care). When the process is viewed through a quality lens, one sees huge opportunity for improvement.

Problems with transitions occur in every Quality domain.

Effectiveness – Transitions are often cumbersome, uncoordinated, and rarely automatic. Moving a patient along is like “passing the buck” rather than a seamless hand over. If patient information can be moved quickly and in a standard way, effectiveness improves dramatically

Efficiency – Transitions are often attended to after other urgent issues, when the patient has already left your care and sometimes as an afterthought. Creating a process for handover that is widely and consistently adopted, with as little prompting as possible, is important so that less time and energy is spent in making it happen.

Safety – Every time care is passed there is a chance that important information, knowledge, insight and context could be lost. This is largely due to fractured communication. Communication issues are relatively easy to fix when providers collectively own the problem. Solutions are as simple as a phone call or as technical as moving a complete electronic record from one provider to another.

Patient Centeredness – The healthcare system often puts responsibility for a transition onto the back of the patient (multiple pages printed out by the hospital on discharge, handed to the patient for their next doctor). There is no thought as to their capacity to follow through, especially if frail or sick. Some hand-offs happen without the patient at all, and this too can be a problem. The job is considered done when a summary is sent by regular mail to a doctor “on record”. This may not even be the correct physician for follow-up, and often it arrives too late. Looking at this from the perspective of a patient’s needs, both habits need to change.

Equity – Transitions in care are not consistent, equivalent or equitable across the province. Interestingly they work best in locations where there are tight provider relationships and there is a sense of shared responsibility. A great example of this is in rural towns where a small number of the same providers are doing the work in each environment: hospital, community and home. Patients move between local clinicians who all know each other, and where there is a sense of joint ownership in helping someone. In large urban centres providers are more disconnected and unknown to each other, so warm hand-offs are rare. This is a “reverse inequity” problem where care in the city, often with more resources, has a lower standard than remote communities. Standardized and automated processes for making a transition happen can correct this, and in Ontario were now seeing a move back to “local” with transformation initiatives.

Accessible – When patients arrive home after being in hospital they often experience problems with access to people and resources in follow-up. Their family doctor may not be aware of their hospitalization, for example, or there was no advice on when to see her. Access is improved if the patient’s primary care provider knows immediately that he has been admitted or discharged. Having complete information makes it is much easier to plan nursing care or home visits, and access is vastly improved.

Given all these barriers to an easy transition in care, what can we collectively do to remove them?

There are solutions at our fingertips right now. Most of these focus on maintaining key clinical relationships, with attention paid to direct communication. Integrated technology can address some of the issues related to standardization and ensuring that information is transferred automatically. For example, OntarioMD has deployed two products that bridge the information gap between layers in the system. HRM, or Health Report Manager, moves discharge summaries, test results, consultation notes and more from hospitals and health facilities directly into the EMRs of doctors and NPs in near real time. Often they have this information to work with even before their patient has arrived home. Nested in HRM is eNotifications, which tell us when our patient has been admitted, discharged or transferred, notifies us of Health Links status, and even activates CCAC, as case coordinators simultaneously receive the same alert.

The availability of accurate up-to-date information, and advanced technology that smooths communications between various levels of care goes far in ensuring that warmer hand offs occur. But technology is not a panacea. Nor should it be seen as a substitute for simple yet impactful relationship-based transitions like a hand over call to the family doctor on discharge. Institutions, providers and patients working together are the ultimate integrated transition team. It is our collective job to make this happen and create a culture of markedly improved quality in the process.

Source: populationhealthlinks.com

The Population Health Quandary: How do we get to where we need to be?

October 22, 2016 / Darren Larsen / 3 Comments

Recently, Primary Care has been moving toward conversations about how we should approach the health of our patients in a more global way. Talk of population health is front and centre. We hear that 5% of the people we look after consume 64% of Ontario’s healthcare budget, and that if doctors and nurses would only work harder on prevention we could keep people out of that zone. The key to driving wellness and reducing he burden of disease in a community is to approach it from a higher level, we are told. Clinicians are very comfortable with the discrete interactions we engage in in every day between individual patients and ourselves, but we are less comfortable with consideration of the wellbeing of larger groups or our patient population as a whole.

We feel disconnected from the problem. Why is that??

I was recently asked by a senior government official to answer this question: “What problem are we trying to solve in population health? And what do we need to do to make it happen?” This is a very complex issue and obviously there are no simple answers, but I believe that a few principles would go along way to getting us there if we approached them openly.

source: continuingstudies.uvic.ca

1) We need to better understand our patient community. This includes collecting data on a large group of patients over time looking for trends, and analyzing the circumstances that surround their health (or lack of it). It is impossible to accomplish large scale population health change without access to data from multiple sources, and this analysis needs to happen in near real-time. Critical data can obviously be found in EMR and hospital records, but increasingly we are able to mix it with information on social determinants of health (poverty, employment status, social networks, and support system), environmental factors (pollution, weather changes, infections disease outbreaks), health promotion programs (recreation, sports, education) and even social media data for very powerful insights. It has been said that data leads to information, then knowledge and then wisdom. With strong analytics in place and some thought on how to act on what we see, we will be able to get to predictions about the value of interventions quickly and accurately.

source: researchinvolvement.biomedcentral.com

2) Change in the health of populations cannot be the sole responsibility of the government or clinicians. Patients themselves must be involved. 99.9% of prevention and care happens without any healthcare provider present at all. It is accomplished by individuals in their homes, and by caregivers assisting with it’s provision. Simply consulting or engaging patients is not enough. They needknowledge and tools for activation around behaviours that are healthy and adaptive.

And for truly effective population health improvement to occur, individuals must be able to both contribute to and work with their own health data. They need line of sight into the record that captures and holds their story. They need a place to curate and store their self-collected health information. They require access to the the same insights and tools that drive change as much if not more than their physicians and nurses do.

3) Reporting to physicians about best practises and where they stand in relation to their peers is not enough. Doctors have access to reports about their practises now if they request them. This happens through EMR searches, contribution to data cooperatives like CPCSSN, EMRALD, or UTOPIAN, and in reports supplied to primary care providers by agencies like Health Quality Ontario (Primary Care Practice Reports).

source: heinzmarketing.com

When received, the reports are usually viewed with some interest, but they are acted upon for change far less often. Driving insight into action for population health management requires mentorship and coaching, and a relentless quest to answer the question “Why?” as much as “How?” And “Who?”. This goes well beyond the carrots and sticks of incentives or penalties. It requires a full scale cultural shift. And at the practice level an organized, validated and robust change management process must be built in.

source: wheel.ie

4) Leadership is required at every level to ensure population health issues are addressed properly. Government, healthcare professionals and patients themselves can champion the cause. Each stakeholder community has a valuable perspective on how to make change happen. When combined, the effect can be profound and long-lasting. We must start with teaching and mentoring to improve understanding of the concepts of population health. Then evidence of benefit comes from analysis of patient and practice data and the performance feedback that goes with it. The hardest step, though, is to translate insight into action. Providers need tools and resources to provide care that raises the bar.

This cannot be done off the side of our desks and in our spare time.

Patients need access to their data to understand where they sit compared to others and to help them understand the responsibility that comes with being part of a larger collective. The health system must also evolve to incubate, promote and sustain the changes that occur. Population health change cannot be relegated to a series of pilot projects. Benefits realized should be made evident as quickly as possible, and how best to scale and spread change needs to be thought about in the basic design of this process.

source: qualcomm.com

5) The move to population health analytics is actually not a technology play. It is a decidedly human one. Success depends on belief in the process and understanding of a common goal. It involves a relentless drive to make individuals and communities much more healthy. Ownership of the work is the responsibility of patients, providers and healthcare planners and participation must be intuitive. It will involve clinics, hospitals, public health agencies, schools and even cities thinking together. We require iterative consultation and creative co-design. There must be some innovation in thought about how we move from individual transactions to care of a community, and how these two are enmeshed. Individual physician/patient relationships can be preserved at the same time as the health of much larger groups is being advanced. If done well this can be a revolutionary shift in how we approach illness and prevention.

A collaborative effort across the spectrum of care will be good for all of us!

Your thoughts and comments are most welcome!

Virtual Care Tools — Why aren’t we using them?

July 20, 2016 / Darren Larsen / 4 Comments

Despite the obvious advantages to both patients and providers of using virtual care tools, they have had very little uptake in the average community practice. There are many reasons for this hovering in the background, from payment models to variable high speed internet access, but the most important of these has to do with office and clinical workflow. In a clinical setting, over time, every doctor and nurse has evolved a way of doing their work that is very efficient and effective for them. In fact, usually this way of dong things has evolved without much active planning. The number of patients needing to be seen is usually matched with supply of service more or less equally. Most visits are in-person in the office setting, or for special issues like palliative care, happen in the patient’s home. In a fee for service world this makes perfect sense. As more and more primary care physicians adopt payment models involving capitation, though, one would think that workflows would have changed to match, but in actual fact they usually have not. Virtual care is almost always offered to patients, when it is offered at all, off the side of the doctor or nurse’s desk. It is supplied as an afterthought. The telephone is partially embedded in our way of doing things. This takes minimal effort. But answering an email from a patient often seems like a foreign task. Text messages are out of the question. And most practitioners will say there is absolutely no time left in the day to perform a visit by video conference or remote monitoring.

So how do we change the conversation? How to we alter the paradigm??

A telephone may still be the easiest and most flexible virtual care tool we have, and it may well be under-utilized these days. Often calls are handled between patients, over lunch hours, or at the end of the day. This may seem convenient when the conversation is short and to the point, but even then there is a degree of stress involved and anything more than a simple problem quickly becomes less attractive. Likely, telephone calls can be handled more efficiently and effectively if we plan them. It seems to make perfect sense to dedicate a period of time every day for handling calls.

Some analysis of supply and demand would be helpful here.

More time for calls may be required on a Friday afternoon or Tuesday after a long weekend to take into account time away from the office. There will be trends and patterns that emerge. Adding in some flexibility is also helpful. If the volume is less, something will fill the time. If volume is higher then there is room to absorb the excess. Patients also benefit from knowing what approximate time period we would be most likely to call them in. That way they do not need to stay close to the telephone for a prolonged period or worry about missing a call for longer than is necessary.

Virtual care visits, either by remote monitoring systems or video conferencing, may well be best treated like other appointments when incorporating them into daily office flow.

They often do not last as long, as they do not involve a physician examination beyond the basics that can be offered though observation on camera, so it is quite possible to double book them into an appointment calendar. This type of visit is often less complex than one which is conducted in person, so perhaps these are best offered at the end of a morning or afternoon when the clinician’s energy reserves are lower. Dedicating time in a schedule for virtual video visits is very welcome by patients, as they can plan to a very narrow margin and make the most efficient use of their time or that of their caregivers.

In the beginning when adopting virtual care, demand will be low. Fewer appointments will be required. However, as patients become aware of the availability of these visits, or when one is offered by staff as they book an appointment or when scheduling online, the number of appointment slots used can be gradually increased.

Secretarial, allied health and support staff play a huge role in the education of patients and their families about the possibilities and limitations of the virtual care visit.

Not every problem is amenable to being seen remotely.

Some degree of triage is usually done when patients call to see their doctor. This is a perfect time to decide if a problem can be easily handled without the patient coming to the office. If such a visit is possible it should be offered to the patient as a first choice. This avoids the virtual care encounter being seen as a lesser or secondary form of care. Online booking systems can also accomplish this task. With a couple of basic questions such as “would you like to have a conversation with your physician using a secure video connection rather than coming in?”, or “in your opinion will this visit require a physical examination or lab test?”, a great majority of visits can be triaged for visit type effectively.

In summary, there is a change to existing workflow when adopting virtual care. In many cases, this is an an opportunity for modernization and incorporating new technology. With just a little bit of planning, careful attention to schedules and analysis of cycles of supply and demand, virtual care can become mainstream. This would make it a consistent part of the suite of services we offer our patients to look after them in the location and manner that best meets their needs.

Source: gapingvoid.com

Trust in the Era of Accountability

May 7, 2016 / Darren Larsen / 6 Comments

It’s amazing to watch a conversation evolve. Over the past month I have had some great feedback from physicians, nurses and patients about medical professionalism and the concept of physician accountability. In my last blog post I explored the idea that accountability is not based on finger pointing or blame and need not be feared. Being accountable, I think, has at its core the concept of matching intent to do well with measuring the outcome of that effort. Accountability, then, is actually rather familiar to healthcare providers. It has always been there in the background, but we often don’t analyze its three components well. For discussion here, the three legs of physician accountability are:

Accountability to our patients
Accountability to our peers
Accountability to the healthcare system that we work in

3-legged-stool

These three integrated and mutually dependent parts are like a three-legged stool. Stability only comes if all three legs are strong. The forces that hold us up must be equal and bidirectional, built into the structure of each leg. Individually one support can flex and bow to a degree, but ultimately all three must be relatively firm for the stool to remain upright.

Many physicians commented to me recently that they feel off balance perched on this stool today. In fact, some told me that it does not feel like they are sitting on a stool at all. The platform they are perched on feels more like a Wobble Board where no stabilizing forces or supports exist. Sometimes they are positioned directly over the single point of balance and feel secure, but stability is always very brief. Any outside force causes them to tip. wobble

So how do we build balance back in? How do we ensure that there are three legs equally pushing up against the forces of professional gravity creating a safe place to sit and work? I believe that strength in these supports can be bolstered and rebuilt. Doing so is difficult in troubled times but can be done through the creation of trust.

Balance can be achieved through trust.

Baroness Onara O’Neill

Many of us would agree that trust has slowly eroded away in healthcare over the past two decades. Some say that this is just the new world order, but I don’t think we can settle for this as an end state. Recently, I was exposed to and watched an amazing TedX talk by Baroness Onora O’Neill, the esteemed Cambridge philosopher and Chair of England’s Equity and Human Rights Commission. Her analysis of trust has caused me to think about its generation and how this influences our professional relationships. In her lecture Baroness O’Neill states that trust cannot simply be built. It must be earned. Offering up opportunities to trust one another is not just the responsibility of physicians but also of the two other partners we work closely with in healthcare: our patients and the healthcare system.

If trust is currently lacking, how to we earn it?

We do so by being trustworthy.

There is an important difference between the trust and trustworthiness. Baroness O’Neill’s thought is that we as humans assess trustworthiness constantly and on three qualities or traits. These are:

balls_in_pillars_800_clr_5427

Honesty
Integrity

Reliability

Trust is actually earned over time as we interact with other people, and this is accomplished by fairly consistent displays of the above three traits. Trustworthiness is naturally evaluated by each of us and can be improved with every interaction. Over time, constant exposure to the principles of trustworthiness mends weaknesses in the integrity of the legs on our three legged stool.

What if our partners don’t want to participate?

source: bonnlaw.ca

There has been a change in the trust balance when dealing with our patients and their concerns over the past few years. In the past patients trusted us simply because we possessed a body of knowledge and insight that they did not. In turn, we hoped that they would return this trust by following our advice because they sought it out and found it valuable. There was an unwritten social contract in the doctor/patient relationship, and there still is. But this traditional trust relationship is much less explicit these days. Patients have exposure to hundreds of opinions and unlimited access to information on the Internet. They are much more able to make informed choices as to how they treat and care for themselves without our expertise. Bidirectional trust is now based on a shared relationship and the insight we can offer in interpreting all of their information through the lens of experience and previous exposure to similar patients and problems. As we adapt to this new reality, if we adapt to it, our accountability changes. It becomes more equal. This pillar is the easiest to keep strong because we understand our patient relationship best and practice to perfect it many times each day.

The second leg of accountability is that of peer to peer. Doctors have had trust and assessments of trustworthiness built into our learning from our very first days in medical school. We take advice often uncritically from our colleagues on how to best care for some of our most challenging medical dilemmas. For the most part we trust their guidance. Yet there is variability in trust based on previous experience and individual interactions with our colleagues. I may wait longer for my patient to see Dr. Jones because I trust her judgement more, where Dr. Smith may well have the same level of competence but is not seen with the same degree of reliability or integrity. I have witnessed a divide in our collective trust over the past few years. Some of this is because of system barriers to maintaining a strong medical community of practice (increasing degrees of sub-specialization, siloed locations of practice where hospital and community physicians rarely mix, trust_fall_pc_2701 fewer personal connections with our peers), some is related to demands on our time time (no bandwidth to follow up about a patient, an increasing demand for service volume) and some is about a changing professional mix in our work environments. With effort, though, trustworthiness can be enhanced between peers in this difficult time. Our relationships can be nurtured with dialogue, direct and honest communication, and by working side by side on challenging healthcare issues. Again, to build better connections we need to increase our trustworthiness. We should treat all of our colleagues the way we treat our friends. We must support a diversity of ideas and multiple opinions on how to solve a collective problem. This will strengthen the second leg of the stool. In doing so, we are being accountable.

source: infor.com

A very important third leg of accountability comes from our intersection with the larger health care system. This includes the structures that surround our work (hospitals, LHINs, community agencies) and the government that funds it most of it (various Ministries and their leaders, both elected and bureaucratic). There has been a huge erosion of the strength of this wooden stool leg recently. Some would even go so far as to say that it has rotted completely. If we agree that the integrity of the wood itself is poor, then it behooves us to find ways to build in strength and resilience. Trustworthiness is hard to assess when you fear that at any time the three tenets of honesty, integrity and reliability are missing. Right now this leg needs external bracing: building up the trustworthiness of both sides of the relationship. Both providers and system planners must strive for ways to show that each is being honest, acting with integrity and exhibiting reliable competency. This will be hard work, especially when our agendas are not the same. And it will not happen overnight or all at once. Trustworthiness is built up with constant exposure to work done in good faith. It involves transparency, patience, careful observation, examination of failures and celebration of success. The relationship does not need to be perfect for trustworthiness to be shown, and we should be careful not to read more into each other’s motivations and intentions than is needed. But the approach does need to be consistent. To succeed at earning trust both doctor and the health system must view each other with open minds and be ready for gestures of cooperation that come with change so that they are not missed when they occur. Eventually a fractured unstable stool leg will be replaced with a stronger one made of new hardwood. It heals. This wood will not be without its knots, but knots don’t necessarily weaken the core of the wood. It remains strong despite its imperfections and is much more interesting to look at. With earned trust, bilateral accountability is easier to maintain.

Professional accountability is balanced and well supported on a three-legged stool when all three legs are intact and strong.

Patients, our peers and the healthcare system form the structure of these three legs and pressure is exerted bidirectionally through each of them daily. Inherent strength and stability of the stool comes from building trust in our partnerships, through consistent displays of trustworthiness as a brace for each leg. Our challenge, and that of our patients and the government during periods of critical change, is to create processes that encourage honesty, integrity and reliability and bolster them when they occur. Over time, less and less effort will be required to find balance, and eventually there will be comfort felt in just sitting, knowing that we won’t fall over.

source: naspa.org

Physician Accountability: a Strategy for Leadership and Professionalism

March 20, 2016 / Darren Larsen / 32 Comments

www.gapingvoidart.com

Recently there has been more and more talk at the health system level about the concept of physician accountability. In Ontario this discussion is part of Patients First LHIN-based initiatives that will have primary care accountable at a local level, possibly with dedicated accountability agreements built into our clinical structures. The issue became even more prominent at the national level last week after a provocative blog post by former CMA president Dr. Louis Hugo Francescutti, which appeared on the CMA website. He went so far as to suggest that it was time doctors participate in a new social contract; one which had them take a strong leadership position in helping to produce large scale system change, and in doing so become accountable for outcomes. Some doctors were angered by his idea that accountability and professionalism were closely linked. There were multiple rebuttals by by those troubled by the thought that we should become responsible for enacting what were purely government priorities. They were especially upset by the fact that this was suggested at a time when 40% of the country’s doctors (those working in Ontario) are without a physician services contract and are feeling the brunt of universal clawbacks to their billings. Dr. Francescutti offered a more thorough explanation of his views in an excellent podcast hosted by Dr. Jason Profetto this weekend. It provided tremendous background to his thinking and is a much better context for discussion than an 800 word blog post could possibly provide.

In reading the responses to his post I started to wonder about a few things:

what exactly is physician accountability? Is this our responsibility?
why do doctors feel so threatened by it? And,
if accountable care in family medicine is coming, what will it take to make it effective, achieving wide scale buy-in and promoting positive change?

My previous blog post on Optimism led to conversations with some of my colleagues and friends around a feeling of beleaguerment in physicians. This idea will be explored in another piece of writing, but the beleaguered physician will naturally push back against accountability. He will say that he cannot possibly put another thing on his plate. He cannot be made responsible for fixing a broken system or for dealing with the inefficiencies he sees all around him. Accountability means new work. It means exposing parts of our practises that may not be effective and in fact commits us to improving them.

This seems overwhelming.

But I believe that accountability is unjustly feared. Perhaps this is because many of us associate accountability with blame, finger-pointing, and even shame. When agreements are hoisted upon people from above, in an environment of deepening distrust, then it is easy to see how doctors are worried that in some way such contracts will be used to punish them.

from oikosofy.com

But I don’t think accountability is about blame or fault-finding at all. If implemented correctly it leaves no power imbalance and is bilateral in nature. With active physician participation it does not need to be implemented in a heavy-handed fashion. It is hinged on measurement, data, and evidence… something we are all familiar with.

Accountability is simply about matching the desire to to do the right thing, with showing that the right thing is actually happening. It lines up intent with outcomes.

Of course there are many discussions in physician circles trying to address “the what” of accountability (which indicators are meaningful?), “the how” (what are the rules governing measurement and reporting?), “the who” (who has the authority to create and enact these agreements?) and “the when” (how often should we look? When do we have enough data to be accurate?). But these questions cause us to become lost in tactical analysis. The real conversation should be more strategic. It should be addressing the question “why?”.

Why do we need to be accountable?

Many doctors will state that we are already accountable, most importantly to our individual patients. But others argue that in fact we may not be accountable enough to these groups. It is easy to operate as physician islands in a churning sea of care when looking after individuals one by one by one. Our cognitive bias tells us that our patients are incredibly well looked after, and in many cases they probably are . They must be very satisfied, as we are good doctors and they keep coming back! The problem is that we don’t know what we don’t know. We don’t often examine outcomes purposefully and we rarely ask our patients’ about their experience. Accountability involves exposing this information under a critical lens and opening up opportunities for improvement. Not only should we physicians be accountable to our patients as individuals, but we also have a unique responsibility for the health of the larger community that we care for. In population-based care the whole is much greater than the sum of its parts. If we step back and look, we will see many opportunities to improve the health of our practices and patients overall.

Another part of asking “why?” involves the concept of being accountable to our peers. Many of us who work in integrated practises understand this already. Some individual autonomy is given up for the good of the group. We are accountable to our colleagues for our expenses, for our patients’ outside use, and for upholding our own internal codes of professionalism. This allows a reliable and stable practice enviroment to be built. Such a practice has inherent flexibility and can react positively to almost any external pressure. Change initiatives which are supported and adopted by practices such as these are more likely to be permanent and to be effective. Also, once we have looked at our own performance, it is very helpful to compare it to that of our peers. Doing so taps into physicians’ unique personality traits that support accountability: perfectionism, competitiveness, and a keen sense of responsibility. These can quicken the pace of change.

A third component strategically asking “why?” Involves understanding our accountability to the healthcare system writ-large. In socialized healthcare it is impossible to deny that the behaviour and performance of physicians has a massive system level impact. Understanding that what we do or don’t do has an effect on system cost and overall sustainability is pivotal here. Measuring and being accountable would show us the effect of our choices and from there we can create programs that garner immediate benefit. Again, to do this well, we must have exposure to reliable data at an enterprise level. Measurement and reporting are key. But a commitment to act on the results of what is being measured is even more important.

Physicians have a huge responsibility for health system improvement. This is not something we can abdicate or delegate, even in the toughest times.

Accountability, in my mind, presents a huge opportunity for our profession. If we have line of sight into our own data first and use it to analyze the quality of our care with the desire for making it the best it can be, then we have taken a very important first step. With that we can begin to compare ourselves to our peers and create meaningful goals and benchmarks to measure against. From there, comparing the same data married to information at the system level provides the ability for physicians to take hold of high-level issues, armed with wisdom and evidence. This will drive meaningful improvement and enhance sustainability.

In showing leadership for accountability we cannot wait to be invited to the table. I certainly hope that we never have to be coerced or forced. Incentives are helpful for starting the process, but they are not all that is required for success. Measurement and reporting are inherent in the process, and this creates discomfort when it exposes our vulnerabilities. But by starting with intent and matching this to outcomes (both known and unknown), we can lead change. Then we show results that will impress even the most cynical health care planner.

Doctors can set the stage for this new scope of work. We should be involved in the development of meaningful measures. We can embrace reporting to ourselves and our peers but also to the larger health care system. With data and knowledge about where gaps exist we can more purposefully work toward filling them and produce real benefits. In my mind, this is true accountability. Doing this well will show ownership of sustainability issues and great leadership in creating an integrated high-performing healthcare system. This is not about blame or the pointing of fingers. Is about stepping up and committing to cooperative change. This is the hallmark of professionalism and I believe it is what Dr. Francescutti was trying to convince all of us of when he wrote.

Your thoughts and comments are welcome!

Optimism in Healthcare Leadership: Finding Water in the Desert

February 14, 2016 / Darren Larsen / 13 Comments

leadership look:feel Recently, after my last blog post, a physician colleague shared that in his opinion, “as usual”, I was “overly cheerful and optimistic”. His comment got me thinking. Could this be true? When conveying a complex message or guiding people toward an often difficult goal, can one be too optimistic? Does optimism alienate people? Is it authentic? What effect does it have on leadership?

Those who interpret a person as being overly optimistic likely think they see the world only through rose coloured glasses. They may believe that optimism is misguided and ignores reality. To be sure, there are daily challenges we face in healthcare which can be overwhelming. There often times when everything around us seems aligned to ensure our failure. Given that, I wonder if it is best to bow to negative forces in our work and life, or counter them? Is being pessimistic the same as being realistic and therefore is more authentic, or does it deny authenticity by closing the door on new ideas? Is being optimistic a delusional belief system or is it really an expression of hope?

“It’s snowing still,” said Eeyore gloomily.
“So it is.”
“And freezing.”
“Is it?”
“Yes,” said Eeyore. “However,” he said, brightening up a little, “we haven’t had an earthquake lately.”
― A.A. Milne

In 2001 I made my first foray away from clinical care in my medical career. At that time I took on part time work as Medical Consultant in a new Ministry of Health agency called OFHN – the Ontario Family Health Network (now Primary Care Branch). Primary care renewal and the creation of the first FHNs was a bold, disruptive idea and five physicians were hired as consultants to flesh out and promote the program . Essentially we were tasked with selling the idea of change to our peers at a time when there was discord and reform was not particularly welcome. There was no formal change management process. We were left to figure things out by trial and error. Back then in public physician forums, I was told I was too young to understand, I was naive, and that I hadn’t experienced enough of the cold stark realities of the health system yet to be credible. Some peers clearly stated that I had “sold out” and “moved to the dark side”. Yet despite that, something encouraged me to press on and kept the spark alive. What was that?

Upon reflection, I think I value certain traits in leadership that allow me to stay focused even in the face of adversity or uncertainty. These include:

an endless curiosity about the unknown
trust in the process I am involved in even if the outcome is not yet known
a belief that the only certain thing in life is change
a general sense that things get better and that the future is exciting

Likely these traits encompass an optimistic world view.

Where do these traits come from? Perhaps they are inherited. Or they are learned as a child. I look to my parents to think about the origins of my optimism, and think especially of my mother. She was definitely a person whose glass was always half full. She believed strongly that virtually all people were good at heart and that if given the choice between right and wrong they would almost always choose “right”. Her favourite word was “fabulous”. Even as her future was slipping away from her due to an aggressive form of cancer she joked, laughed, sang and remained positive about every aspect of life. Maybe I am a reflection of that.

But the statement of my colleague that I was overly optimistic challenged my approach. When I am leading with optimism, is it possible that I am overlooking something? Am I avoiding the painful realities of the current state of health care, where budgets are tight, people are worked past capacity, supply and demand never seem to balance and pessimism easily prevails? Is being optimistic simply missing the mark? Hopefully not. An optimistic approach to leadership does not neglect the real need for critical analysis. True optimists are not blind to the risks and challenges they face every day. They tend to acknowledge pain points and think through how they can be addressed quickly yet effectively. This allows them to look forward to the next goal and the new trials that come with it. Optimists address challenges. They tend not to be threatened by them.

Interestingly, pessimism is rampant in doctors. A survey conducted by the Physician Foundation in 2012 found that pessimism was firmly implanted in American physicians’ minds. There, “over three quarters of physicians – 77.4 percent – were somewhat pessimistic or very pessimistic about the future of the medical profession.” Yet surprisingly, in a survey of 800 Americans in 2013 via Statista, half of them self report as being optimists, while only 4% describe themselves as pessimists, and 43% say they are somewhere in between. And if my profession is much more pessimistic than the general population, is there room for optimism in its leadership? I would suggest … absolutely yes!

“You’ll never find a rainbow if you’re looking down”
― Charles Chaplin

In business literature, optimism is seen as one of the most important traits of good leadership. In a recent Forbes magazine article on leadership, Carmine Gallow proposes five reasons why optimists make better leaders.

Optimists see opportunity where others see uncertainty and despair. This is critical in a time when radical health care transformation initiatives are the norm as we are experiencing in Ontario right now.
Optimists are inspiring and effective communicators. They can get a message across effectively as they stand out among the white noise of negativity.
Optimists rally people to a better future. They show others hope, which is key to surviving periods of hardship.
Optimists see the big picture. They do not get caught up in the cycle of circular negative discussions or thinking. They can see above and beyond today.
Optimists elicit super human effort. They cause others to use their energy in ways that surprise them. They attract many followers who are happy to work on their cause.

And in thinking how I most want to lead change, I am constantly comparing myself to others and asking who is it that I would climb a mountain to follow? What do they look like? What do they do or have that motivates me? Whatever it is, I want to emulate them. Great physician leaders are everywhere around us. They are busy working away showing positivity in the face of adversity. They seem fearless when others are withdrawing. From them I derive strength. I count these people among my closest friends, and that gives me inspiration.

Realistically, our time on this earth is short. We have only a small window to create and enact positive change. To do this well we must use the same energy that some put into pessimistic and negative thinking, and channel it to productivity and the advancement of new ideas. Being optimistic is the single biggest advantage I have in the work I do, both in medicine and in healthcare leadership. Every day I draw upon the energy of others who do the same, and the partnerships that are created in this combined effort have the most amazing potential.

And the best thing is, with this optimism I am able to look forward to virtually every day and the challenges and opportunities that lie ahead in it. To to be branded excessively cheerful and optimistic is, I suppose, a compliment. It is a sign that I have succeeded.

Your thoughts are welcome! And of course I just have to say it…. Keep smiling!

“For myself I am an optimist – it does not seem to be much use to be anything else.”
― Winston S. Churchill

Mature EMR Use: a Twitter Conversation

February 9, 2016 / Darren Larsen / 2 Comments

EMR

We have come a long way in Canada in getting physicians to adopt digital records systems in the form of office based electronic medical records (EMRs). In Ontario alone over 11,600 physicians (both family doctors and specialists) have EMRs in their practices and are using them with varying levels of sophistication.

For many of us, the EMR is our lifeline to our patients.

These systems are the environment in which we physicians spend almost all of our day, recording the patient story, reading and thinking about test results and communicating with their peers externally through the creation of referrals, and internally with messaging systems. Some clinics are starting to push the boundaries of basic use, though, and this is where the power of digital records systems becomes apparent. This is not easy work. The thinking required to move to mature EMR use takes reflection and solid dedicated effort on behalf of physicians, nurses and the staff they employ and is often done off the side of the desk. We are challenged with advancing mature EMR use in basic concepts of change management. How do we convince users of the benefit of moving forward? How do we make the work palatable in the face of all the other demands facing them every day from the clinical, business and system perspective? How do we do all of this in an already strained system with fewer and fewer payments for participation?

There is a tendency to look to our American neighbors in their advancement of EMR Maturity, but models there have been built on massive incentive payments without necessarily a view to how the change can be sustained. As well, many clinicians are involved in accountable care contracts with various gain sharing and risk sharing strategies that make the work in maturity more pertinent as there are direct benefits to business groups and a time investment in changing behaviour pays off quickly. But the Canadian environment is different.

Tomorrow (Wednesday February 10th at 1 pm) I will hosting a “Tweet Chat” with @HCSMCA. During the short hour we have to chat we are hoping to explore barriers and opportunities in the advancement of EMR use in our environment, especially the community EMR space. This applies to both primary care and specialist thinking. We are posing four big questions to advance the conversation and are hoping that you have some great ideas to promote change.

T1: How do you use your EMRsnow? What do you value most in it? As a health professional, patient, researcher, etc.
T2: What would the EMR of 2030 look like? Where do we need to get to?
T3: What could/should be done w/ the vast data in EMR systems to improve patient care, relationships & the healthcare system?
T4: How to move forward/promote the advanced adoption and use of mature EMR systems?

This promises to be a very interactive conversation about the possibilities of community based EMRs, and how they can be used for truly positive change!
#HCSMCA

What am I doing here?

February 9, 2016 / Darren Larsen / 5 Comments

For the longest time I have loved writing.

As a kid, I used to escape in letters to friends in far away places, stories of adventure and recorded observations of the world around me. I hated diaries, though. I didn’t want to write things that simply listed the events of the day, attached to static information like weather, games, sports, vacations and the like. What I loved were ideas. My pen gave me the freedom to roam through random thoughts…. things that were disconnected could often find attachments to other imaginings. Things that appeared confusing would start to make sense. Brief mental interludes could be expanded to longer stories and some sense could be made of things that brought wonder.

And it was all done on paper.

Thoughts go better with paper.

For the most part, the act of writing was an act of processing. It was a reflection of the way I learned. Outlining ideas… giving them texture… writing in detail. This was best done with pencil and an eraser. The odd time I would have to go back and make changes, to reword things so that thoughts flowed and ideas aligned. Now we have computers. Online editors. Copy, paste, highlight, delete. Thoughts on the keyboard are quicker, but somehow lack depth when I write. So, even now, it starts with pencil on paper.

So what am I doing here?

In our crazily busy days, it seems that there is no time to sit and reflect. There is little opportunity to tie together random ideas and thoughts into a more productive narrative. Notions are lost because they cannot be thoroughly explored, and connected with others, or even shared. In this world of 140 character meaning, we lack the mental space to think bigger and to explore. As well, as we age, ideas come in a much larger context of experience and with much more meaning and rich context attached. Writing ensures that there is room to pause, reflect and conclude thoughts that seem to constantly pop in and out of consciousness.

First, when I thought about writing, I was struck with the sense that I had nothing useful to say. At least, I had nothing to say that others would want to hear. And maybe not everything will be read. Perhaps some ideas will remain private and never be shared. But the possibility of putting them out there for comment, review and even to start a conversation is exciting to me. These words are not the end of a line of thinking. I see them as the beginning.

So welcome to my blog. Here I will be exploring topics of quality in healthcare, ehealth, education, leadership, and more. I hope you will read to the end. I hope you will add your voice. I hope to remain relevant and do all of this with a sense of curiosity and fun. Stay tuned….

Darren.

PS. At the exact same moment I was writing this, Dr. Shawn Whatley posted an excellent piece in his blog about “Why Doctors Should Write”. It can be found at shawnwhatley.com . Excellent read! He inspires many of us…..

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