Categoryhealth policy

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

emr-systems-are-working-to-improve-population-health-outcomes-_1059_529759_0_7074829_500

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

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

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

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

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

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!

Trust in the Era of Accountability

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_2701fewer 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

www.gapingvoidart.com

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:

  1. what exactly is physician accountability? Is this our responsibility?
  2. why do doctors feel so threatened by it? And,
  3. 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

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!

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