| A movement
is afoot to improve your health (and the whole country’s
health), give you a better healthcare experience, and lower your
healthcare costs. After three years this movement has shown spotty
success by some measures, but I think it holds lots of promise
and deserves continued support. Why should you care? Because your
doctors and other care-givers will do a better job (and keep you
healthier) when they can work on your problems together, and with
more information at their fingertips. That’s what the new
National movement, the Patient-Centered Medical Home (PCMH), is
about. Colorado’s main version of this is Health TeamWorks.
They are leveraging the advent of the new electronic patient records
along with creative office systems to make best use of the new
records. But first, some back story.
The first patient information system that actually helped me to
be a better doctor was a prenatal care program developed and promoted
in the late 1980s by the malpractice insurance carrier for the
majority of Colorado doctors, COPIC. COPIC consultants had designed
some forms to be filled out for each pregnant patient’s
visit. It was color-coded, annotated and backed up by a well-referenced
handbook that spelled out just what to do in the case of each
abnormality encountered. COPIC trainers needed just a few hours
to get practitioners up-to-speed with their user-friendly system.
It’s no coincidence that it was a malpractice insurer that
developed and promoted this system. Obstetrics has always been
one of the highest liability risks for a doctor. Deliver an imperfect
baby and you’re at significant peril of having an attorney
or two pouring over the medical record, starting with the first
prenatal office visit and ending when the child bumps up against
the statute of limitations at the age of eight. With the help
of the COPIC record, periodic testing and deviation from normal
trends in fetal development was much less likely to be overlooked.
Thanks in part to this excellent system, malpractice insurance
rates for Colorado obstetricians fell from $62,000 to $24,000
per year between 1987 and 2002 – that’s 61 percent!
But, one of my colleagues asked, was this smart medical record
a crutch that kept our doctors-in-training from really learning
and committing to memory the things they needed to know? What
about facts like when in the course of pregnancy to order blood
counts or when to worry that the mother’s tummy was too
big or too small for her stage of pregnancy? Weren’t we
doctors supposed to know these things by heart?
For the most part, the doctors who deliver babies do know these
things by heart. But there’s so much to keep track of, it’s
easy to overlook a thing or three in the course of a busy day
in clinic. An organized system is essential to providing the best
patient care. That’s what I told my doubting colleague.
It’s much better that residents learn they need systems
to support their practice than to go on believing, as they’d
been taught in medical school, that competent care was almost
wholly a function of the quality of the doctor’s memory.
Two decades later, there still aren’t a lot of patient information
systems making an impact like the COPIC record did on obstetrics.
Enter Health TeamWorks.
In October, I attended a Health TeamWorks conference. Their goals
are way beyond what the folks at COPIC ever imagined in the 1980s.
Health TeamWorks is a non-profit coalition of health insurers,
physicians, hospitals, employers, government agencies and other
entities founded in 1996 under the name Colorado Clinical Guidelines
Collaborative.
For now, the Colorado team is concentrating on two common diseases,
diabetes and asthma. There are clear protocols, supported by tons
of excellent studies, that outline what ought to be done at what
intervals, in terms of patient education, testing, examinations,
and medications, for these two chronic diseases.
The challenge lies in remembering the many things to measure,
examine, teach, and prescribe. Managing these diseases lends itself
to the sorts of flow sheets that COPIC developed for prenatal
care. There are already plenty out there for diabetes and asthma,
in both paper and electronic formats.
As always, the problem with getting things done right lies not
so much with the system itself as with how people use it. That’s
where Health TeamWorks comes in. They start with the assumption
that even for super-bright doctors, unaided memory is a very shaky
foundation upon which to build good healthcare. On-site coaches
get the whole staff involved in developing a system to take better
care of patients. Doctors like the program because, in exchange
for giving up some of their over-rated independence, they are
unburdened from having sole responsibility for remembering and
taking care of every little thing, like recommending flu shots
each fall to asthmatics.
All of the practices and health systems represented at this conference
are committed to doing things a new and better way, from receptionist
to doctor. They brought posters to display their progress. After
up to three years, the graphs of results of things like percentage
of diabetics who’d had pneumonia shots or of asthmatics
who self-monitored their airflow were mostly pretty flat, showing
little improvement over time. It will take longer than everybody
had hoped before this effort to rationalize and coordinate care
delivery in the average doctor’s office can show much improvement
in patient outcomes. We’re also going to have to figure
out how to make it pay, considering all the extra time and effort
that goes into practice re-design. Right now, the movement is
making it on grants and other sorts of one-time incentives.
Notwithstanding the shortage of measurable results and the cloudy
financial future for primary care, the enthusiasm and level of
creativity of the conference participants more than convinced
me they are on the right track. If you’re lucky enough to
be a patient at one of the sixteen Colorado primary care practices
that has chosen to get with the Health TeamWorks program, I think
you’re going to love the results.
Get more info at www.coloradoguidelines.org
Marc Ringel has spent the majority of his career as a family
doctor working in rural communities, including the last 12 years
in Brush, Colorado. He has written extensively, for lay and professional
audiences, about rural health, medical informatics and healing.
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