Monday, August 24, 2015

Measuring the Doctor-Patient Relationship

Sixty years ago, before he became a controversial figure in the field of psychiatry, Dr. Thomas S. Szasz co-authored an article for the Archives of Internal Medicine (now JAMA Internal Medicine) on “The Basic Models of the Doctor-Patient Relationship”, which is well worth reading today, particularly for those who believe that patient empowerment/engagement is a novel and disruptive innovation of our digital times. The paper is describing three distinct relationship models (i.e. active-passive, guidance-cooperation, mutual participation) and how they flow and morph into each other based on patient ability/preferences, physician characteristics, and illness circumstances. Dr. Szasz is addressing all the contemporary hot buttons of paternalistic doctors, patient values and shared decision making, but more important is the realization that doctor-patient relationships were a concept debated before most of us were born, in much the same way they are debated today.

Since Dr. Szasz made his contribution to the philosophy of medicine before hidden agendas and political correctness dictated how ideas are phrased, he was free to observe that “each of the three types of therapeutic relationship is entirely appropriate under certain circumstances and each is inappropriate under others”, without the compulsory need to assign blame to either the patient who prefers passivity or the physician who complements those preferences in “an interlocking integration of the sick and his healer”. And when a mismatch arises between the preferences of doctor and patient, the relationship is dissolved, “and so life goes on”. But the days of laissez-faire medicine are over, and today we feel compelled to define the, one and only, ideal physician-patient relationship.

As the managed care era descended upon us in the 1990s, Dr. Ezekiel Emanuel felt it necessary to define an aspirational goal for the ideal physician-patient relationship based on six fundamental components (the six C’s):
  1. Choice – For patients, this means choice of practice type and setting, choice of primary care physician, choice of specialist or facility for emergencies and special conditions, and choice among treatment alternatives.
  2. Competence – Physicians should stay up to date, have good technical and diagnostic skills, exhibit good clinical judgement and be cognizant of their own limitations.
  3. Communication – First, physicians should listen and understand symptoms, values, family, jobs and other health related patient concerns. Second, physicians should be able to explain the disease, the diagnosis, treatment alternatives and how those affect patient values, guiding patients through issues raised by their illness, while respecting patients’ preferences for how much they want to know.
  4. Compassion – This is about empathy and helping patients feel supported.
  5. Continuity – Here the paper recognizes that the “ideal physician-patient relationship requires a significant investment of time”, and that frequent changes of physicians undermines such relationship. It also acknowledges that “relationships that endure over time may be more efficient” both by helping doctors treat the patient in more appropriate manner and by fostering patient trust and confidence.
  6. (non) Conflict of interest – Personal and financial interests are emphasized, but the expectation seems to be that “a physician’s primary concern will be his or her patient’s well-being, even though physicians may have obligations that conflict”.
The remainder of his paper explores the many ways in which managed care is positioned to attack all six components, and concludes by stating that “the physician-patient relationship is the cornerstone for achieving, maintaining, and improving health”.

Dr. Emanuel’s definition of the doctor-patient relationship is very broad, and with a few minor additions and deletions, it can also serve as a definition for what we now call patient-centered care. Perhaps it is not by accident that the term “patient-centered medicine” was introduced into common parlance by Enid Balint, the wife and collaborator of Michael Balint who was one of the earliest researchers of the dynamics between doctors, patients and illnesses. Michael Balint went as far as to suggest that the doctor himself was actually a therapeutic “drug”, while Enid Balint envisioned the skills needed in the practice of patient-centered medicine to be “in the way that the doctor allows the patient to use him, rather than in the way the doctor responds to the patient by his interpretations and theories”.

Whereas the contemporary definition of the physician-patient relationship (and subsequently patient-centered care) consists of a rigid set of presumably ideal physician characteristics, the Balints, and to a certain extent Dr. Szasz, saw the physician as a tool to be personalized by each patient and further customized for each illness situation. It is difficult to imagine a more egalitarian or participatory relationship than this one. In fact, Dr. Emanuel’s six C’s can be seen as just one particular facet of the malleable relationship proposed by Enid Balint. In a perfect world, we would concentrate on creating an environment where physicians are able to allow themselves to be used by patients, and trust that good things will happen to both parties as a result.

But in our current world of ingrained distrust and defensive measurements, we feel compelled to digitize, tabulate, rank and rate the doctor-patient relationship, just like we measure everything else. First, the ubiquitous patient experience surveys provide a coarse measure of how patients experience the communications component of the relationship. It is interesting to note that patients are not asked about their preferences, but whether the “provider” did this or did that, presuming that this or that are what the patient wants the “provider” to do in all situations. Can we infer from a highly scored experience survey that the patient has a useful relationship with her doctor? Not really.

Then we have the periodic surveys asking patients to rank the importance of physician attributes, which always include physician compassion and communication patterns, but rarely other components of Dr. Emanuel’s six C’s, and never the chameleon abilities proposed by Ms. Balint. The presumed intent here is to impress upon physicians that they should focus on the highest ranked attributes of the relationship because they matter more often to more people. Some researchers went as far as to define frameworks for measuring the relationship itself, and formal screening instruments to score it from a patient perspective. Those tools seem a bit more pertinent since the questions are about the patient and her perceptions, instead of inquiries about sanctioned physician activities, and because no assumptions are being made regarding the “right” kind of relationship (a Dutch example is depicted below).

Perhaps a combination of the former and the latter, along with objective information, such as assessment of choice, conflict of interest and competency, can get us closer to a meaningful measure of the doctor-patient relationship. Careful analysis of result sets would allow us to answer two basic questions: are patients getting what they value most, and are those fortunate enough to have the relationship they desire experiencing better medical outcomes. Examining the characteristics of both patients and doctors, could yield actionable insights into optimal practice models. Strangely though, in spite of the billions of dollars spent on “patient-centered” research to date, I am not aware of any such study, or serious attempts at anything remotely similar. One can only wonder why.

Although there is ample rhetoric about the doctor-patient relationship and patient-centered everything, much of what we do in health care today is in stark contradiction to Dr. Emanuel’s ideal six C’s, not to mention the revolutionary ideas of the Balints. Patient choice is being curtailed by a bewildering array of narrow network health plans and wholesale clinical decisions made by corporate CEOs. Competence is being redefined to include care provided by non-physicians, non-clinicians, and algorithmic software. Continuity of care is being discouraged in favor of cheapness, convenience and continuity of medical records, while conflict of interest is inherent in all so called value-based arrangements. Compassion has been scripted by marketers, and communication, precisely codified for the eclectic, self-managing, highly educated, financially secure, and largely healthy, patient segment, has become the second most important factor defining the interaction between patients and the health system. The premier factor is of course, access to all of the above.

I don’t think I can agree with Dr. Emanuel’s opinion that the physician-patient relationship is the “cornerstone” of health, but it might very well be the cornerstone of healing. I don’t know how healing the sick affects the myriad measures we are currently collecting, reporting and analyzing with such zest. Some argue that a satisfactory doctor-patient relationship is conducive to patient adherence, increased ability for self-management, and decreased utilization of hospitals and emergency services. If these assertions are even partially true, then the doctor-patient relationship has serious implications for the most important aspect of health care in this country: money. And as such, defining, supporting, and, yes, formally measuring and analyzing the doctor-patient relationship may present a rare confluence of interests between corporate greed and basic human dignity.

Monday, August 3, 2015

The DoD EHR: Ah Hell, Let's Try Again

The health information technology (HIT) world has been hit by a watershed event like no other. The Department of Defense (DoD), widely respected for its indiscriminate generosity to contractors, has awarded the most coveted prize in recent HIT memory – the Defense Healthcare Management Systems Modernization (DHMSM) contract. And the winner is... Leidos, the contractor formerly known as SAIC. A couple of years ago, when the race for the DoD contract began, Leidos/SAIC selected Cerner as its EHR of choice for this contract. The smart money though was on Epic and its Big Blue partner because they are and seemingly always have been the safest procurement choices for top brass in any large organization.

A stunned HIT “community” initiated its favorite game of providing post facto authoritative explanations ranging from cute to grotesque. Here are the most common and least specious opinions. The interoperability lobby offered Cerner’s recent and vocal leadership in organizing a national information exchange as the reason for the DoD choice. Others, who may have been bothered in the past by the prices Epic was able to command, suggested that the relative cheapness of Cerner must have tilted the balance. The technically inclined opined that the Cerner architecture is more modular and hence a better fit for DoD needs. These theories and more may all hold some truth, but what we all seem to forget is that the DHMSM contract was awarded to Leidos, and Cerner is just a subcontractor.

In September 2013 the Science Applications International Corporation (SAIC), one of the largest defense contractors in the U.S., changed its name to Leidos Holdings, Inc. and spun off a smaller entity that retained the SAIC name. The split was explained as a way to avoid conflict of interests and get more business. The classic SAIC expose, written by Donald L. Barlett and James B. Steele, and published in Vanity Fair in 2007, should be required reading for anyone trying to understand why the DHMSM contract award was pretty much preordained. Epic lost the day it partnered with IBM, and Cerner won the day it selected, or was selected by, SAIC.

Back in 1988 SAIC was awarded a $1 billion dollar initial contract to design, develop, and implement the Composite Health Care System (CHCS). When the first version of the CHCS turned out to be lacking, SAIC was awarded a contract to replace it with CHCS II. Over 27 years SAIC has evolved the CHCS into the current Armed Forces Health Longitudinal Technology Application (AHLTA) through design, redesign, rip-and-replace, integration and deployments in military facilities of all types around the globe. The DoD was very proud of the new $1.2 billion AHLTA back in 2005, but in time it became fondly known as an acronym for “Ah Hell, Let's Try Again”. Nevertheless, SAIC kept raking in support and development contracts for AHLTA, since according to the DoD, SAIC “is the only vendor capable of supporting functional and technical system changes due to their unique experience and familiarity with the system”.

After CHCS and AHLTA, now comes DHMSM, and there is absolutely no reason to believe that the DoD changed its opinion regarding SAIC’s unique capabilities. Spending billions of dollars on one failed solution after another does not seem to be a problem for defense contractors, or government contractors in general, and in all fairness SAIC does have decades of experience in the unique deployment needs of the military, which are vastly different than your typical posh academic center in the homeland. Perhaps throwing a decent commercial EHR in the mix will finally break the perpetual cycle of failure the DoD has become accustomed to paying for. One can only hope.

The more interesting question for non-military HIT is how the DHMSM contract will affect the orders of magnitude larger commercial EHR market. Will Cerner leapfrog Epic and become the EHR of choice for large health systems? Will Cerner be so bogged down in military work that it will start losing ground in the private market? Will Epic repent and submit itself to the Cerner led CommonWell interoperability (data collection) bandwagon? Or alternatively, will Epic snap out of its self-imposed silence and mount an aggressive marketing and PR campaign? Will distant competitors somehow be able to take advantage of the turmoil and take the market by storm? Or maybe, just maybe, once the headlines die down in a few weeks, and we move to the next big thing, nothing will have changed.

The DHMSM contract is very large by comparison to private EHR contracts, but it is not as large as it looks. The initial award is for $4.3 billion over the next 10 years. Multiplying by at least 2, since after all this is a Pentagon contract custom built for SAIC, we are looking at approximately $860 million per year on average, over the next decade for SAIC, Cerner and dozens of other subcontractors. An optimistic estimate of Cerner revenue would be around $80 million per year (HIStalk estimates a more conservative, and probably more realistic, $40 million per year). To mere mortals this may seem like a lot of money, but considering that typical hospital EHR implementations run anywhere between tens to many hundreds of millions of dollars, and considering that Cerner has annual revenues of around $4 billion, the DoD contract seems like a modest contribution to an already gigantic EHR powerhouse.

Speaking of money, it does seem rather excessive to spend so many billions of dollars on a piece of software. Nobody knows how many billions will end up being spent, but we do know that $4.3 billion is the absolute minimum over the next 10 years. Is that a lot? The DoD has 55 hospitals and more than 600 clinics, and it has aircraft carriers, submarines, helicopters and all sorts of personnel carrying vehicles where the EHR will need to be used, not to mention remote caves in foreign lands, and theaters of full blown war. Neither Cerner nor any existing EHR, including VistA, has those capabilities out of the box. Certainly lots of new code will need to be written by Cerner, but the bulk of the money will go to integration and deployment. That money is SAIC money and is independent of EHR choice (this is a good place to go back and read that Vanity Fair article).

There is however no doubt that the DoD contract is a huge marketing win for Cerner, and this is amplified by the fact that Epic does little to no public marketing of its own. The Cerner award will also have beneficial effects on the CommonWell data exchange platform. The already significant influence Cerner exerts on government agencies, such as ONC, will likely increase and that’s a very good thing for Cerner’s commercial business. More important though is Cerner’s foot in the door at the Department of Veteran Affairs (VA), just in case they decide (or are forced to decide) to keep up with the DoD and replace their VistA EHR.

So far the experts and the media have been kind to Cerner, and will continue to be so as long as the DHMSM project moves successfully through its milestones. However, as a subcontractor, Cerner has limited control over the project as a whole, and considering that in the world of SAIC, success is defined as extracting the largest possible annuities from the government, whether its deliverables are fit for purpose or not so much, Cerner is running a significant risk of having its otherwise respectable reputation tarnished through no fault of its own. Not sure why, but my feeling is that Cerner has a much better chance of surviving inside the shadowy defense contractor culture than Epic would have ever had, so things may turn out just fine.

Health care nowadays is like the ticker tape of a hyperactive stock market gone mad. Everything is huge, disruptive and transformative for a few days until the next seismic shock rolls in. Since nothing means anything in particular, everything means exactly what each expert wishes it would mean. For some the DHMSM exemplifies the triumph of interoperability and the demise of information blockers. For others it is clear proof that the future belongs to platforms and substitutable modules. Many are just thrilled to see a previously unbeatable contender take one squarely on the chin. And a few feel personally persecuted because a big iron EHR vendor was selected instead of something from the app store. Truth is that the DHMSM means very little to anybody in the EHR industry, other than Cerner of course.

Sunday, August 2, 2015

Excerpts from a Doctor's Personal Journal


4/18/13 …finally certified as a PCMH with NCQA. We’re meeting Meaningful Use requirements and are busier than ever. It seems I’m staying at the office later and I haven’t seen any of the expected profit yet, most of the increased reimbursements have barely offset the added costs as far as personnel and IT, but now we can prove the quality of the care we provide…

4/25/13 …at dinner with the family I realized how chaotic my home life is, no structure like at work. I was late getting dinner ready, Thursday is my night to cook, and I didn’t have all the ingredients so I had to run to town and still forgot to buy milk. I needed to pay bills but hadn’t transferred any money to the checking account and had used up the last of the checks without ordering more…That night the twins Annie and Amy were pestering my wife Kate about soccer camp, and Glen was talking about his latest baseball game, he made the varsity baseball team as a sophomore playing first base. Kate, who runs her own business as a florist, observed that at work she has systems to track orders and deliveries, but at home we can run out of milk and no one says anything. It got me thinking…

5/16/13 …after dinner the kids had finished their homework and were starting a game of Monopoly and Kate was about to settle down with her book when I called everybody together for an impromptu family meeting. I proposed that we build a Family Centered Personal Home (FCPH) based on the same principles of the PCMH I had learned at work. I suggested we could have written family procedures and protocols for all the important stuff, and we could track our progress if we digitized and automated as much of it as possible. We would develop a team approach with everyone functioning at the top of their abilities. The kids were excited when I told them we would each need our own IPad connected with the home computer, but Kate was skeptical and wondered how it would help and what it would cost.  Eventually my enthusiasm prevailed and Kate agreed to try. I know that if we can collect enough data and use the right quality metrics we can optimize the FCPH…

8/22/13 …it’s taken all summer but I think we’re ready to begin in time for the start of the new school year. I used all the spare time I had this summer writing protocols for everything from paying bills to homework and piano lessons. I took the money we would have spent on weekend outings and invested in a new home computer and IPads for everyone. I had an IT guy at work help me modify some basic software and spreadsheets to structure our initial data collection, later I’ll need to invest in better software to help interpret the data we collect…

8/29/13 …Ready to roll! I explained tonight that the new computers are tools and not toys, we’re going to use them to track our progress. I showed each of the children how to use the preloaded spreadsheets to track their time spent on homework, chores, piano and violin practice, school attendance using GPA as an outcome metric, and so forth. I included detailed procedures for everything from teeth brushing to basic hygiene and meal prep, expectations for laundry, vacuuming, dishwashing, and lawn mowing... Glen was excited to see I’d included a program to track his baseball batting average. It’s important for children to have some unstructured time to pursue their own interests and hobbies so I built that into the detailed preloaded schedules customized for each of them. For Kate and me, we have the added responsibility of tracking household finances, kitchen and pantry inventory, transportation expenses maintenance and repair, etc. I mirrored some of the children’s software on our computers too so we can have reminders of important events like recitals and soccer games….

8/30/13 …today I introduced the family to the rest of the team, just as with the PCMH Kate and I can’t be expected to do it all, so I’ve hired some surrogate help in the form of tutors, nanny, personal trainers, gardener, and housekeeper. I have outsourced accounting, IT development and most home maintenance responsibilities. Extended family can step in to fill some functions when Kate or I aren’t available. I’ve had to forgo any retirement savings this year and we might miss a mortgage payment or two, but it will be worth it in the name of quality…

9/2/13 …I had to password protect the Intimate Relations protocol and data set on the shared server, it was generating too much interest. I need to talk to Kate about measuring quantity as well as quality as a metric…

10/10/13 …pulled Amy aside tonight and had a stern father-daughter chat, she just hasn’t been tracking her data like the rest of us. She complained it was too much work, that all the data entry was actually keeping her from performing the tasks she is supposed to track. I explained that I completely understand, and that based on my experiences at work the documentation is always more important than anything else so sometimes you have to fudge a little bit in order to get everything done. Without the data we can’t measure how well we’re doing and if we can’t measure it how can we improve? She cried and tried to argue that sometimes the intangible things in life are more important, but in the end she saw things my way and promised to try harder…

12/12/13 …During dinner tonight everyone was quiet, the cacophony of conversations we would have heard last year at this time is gone, instead everyone has their head down rapidly pecking away at their computer screens documenting their activities of the day…we don’t seem to be interacting nearly as much but the pantry is well stocked and the oil/filter in the pickup was changed on time for once…

1/16/14 …reviewed the children’s report cards from fall term and Annie’s grades have fallen. Looking through the automated reporting features of our user friendly software it appears she has been keeping up with her homework, and the chore tracking feature reveals 100% performance, everyone else is tracking around 65% to 80% with a performance incentive set at 72.3%. My personal observations make me question the veracity of Annie’s outcomes, but it’s hard to dispute the data…

2/13/14…Glen is in the front yard playing catch with Nathan his personal trainer, the twins are at the kitchen table with Brenda their mentor working on their algebra, both tasks I used to have to do. This has freed me up to do more important things… I just discovered all the tires on our mountain bikes are flat, they’ve probably been that way for months and nobody noticed, I’ll need to add a bicycle tire pressure monitoring protocol to Glen’s garage inventory and maintenance duties, maybe I should sell the bikes, we haven’t used them in almost a year…

3/27/14 …spent the first couple of days of spring break tweaking our protocols and procedures for the FCPH and letting the kids catch up on their reporting. Was surprised to learn that Glen isn’t going out for baseball this year, he says he just doesn’t have the time…

5/15/14 …Amy is still having a hard time, tonight she complained that our relationships are suffering, she observed that we haven’t played a game of Monopoly in over six months and our dinner conversations are curtailed as we all rush to finish the meal and clean up so we can complete all the documentation needed for the FCPH. It was difficult for me but I had to explain to Amy that in any endeavor like this sacrifices are necessary. At the office before we became a PCMH I used to think that my relationship with my patient was paramount and that I could effect a better outcome by getting to know and bonding with my patients respectfully. Our transformation to the PCMH taught me that I wasn’t doing such a good job. Some of my patients that I’d been treating for years weren’t following my advice and were skewing the metrics used to incentivize me so they had to be discharged from care. I explained to Amy that just as I’ve had to sacrifice any antiquated notions about relationship building in clinical medicine in order to optimize my outcomes, so too must she jettison any such unreasonable expectations as we perfect the FCPH…

6/18/15 …our household is running like a well-oiled machine, and I can prove it! We had to let the housekeeper and gardener go so we still have some issues in those realms, but everyone has very well defined roles and responsibilities… sometimes there can be a lot of finger pointing when things go wrong. I haven’t talked to Amy in weeks, there are still some discrepancies in Annie’s data and actual outcomes I haven’t put my finger on yet, and Kate seems more distant somehow. Glen no longer talks about going to medical school after college. On the computer I can show you how we’ve improved on so many metrics in the last two years, I can’t imagine trying to run a household without the FCPH…

The author is a family physician in solo practice.

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