Monday, 15 January 2018

The orientation to the patient: a health service as a "service"

Sophia Schlette

One year ago, while I was still working for Kaiser Permanente, I was invited to give a talk on primary care concepts in an adult education academy in the vicinity of Berlin. I thought I would present a theoretical framework of evaluation, based on evidence, consisting of ten dimensions, similar, but not identical, to the ten building blocks of Bodenheimer already presented in this blog. I arrived on the previous afternoon and saw the participants with a certain air of frustration in being saturated with so much theory. The models and concepts of the talk had little to do with the experience in the German medical practice or with the doctor-patient relationship in real life. In Germany, if you go to the doctor, you have to take half a day off. Wait up to 40 minutes, despite having an appointment just to have 5 precious minutes with the doctor. Typically, neither the doctor nor his employees will give any explanation, nor apologize for the delay. There is no electronic medical record everywhere and where there is, the doctor begins to read it only when the patient is present: “Here’s the recipe. Have a good day. Goodbye” This is the German system, as we know it since childhood.

Returning to my lecture, I was worried. How could I awaken the interest and raise the attendees’ spirits? How could I give this audience a presentation that would bridge the gap between theory and practice and convey, at the same time an idea of ​​a different practice, no matter how well it’s established elsewhere? I spent the night thinking about it and decided to prepare an impromptu presentation, without slides. On the other hand, I opened my personal Kaiser Permanente patient electronic file, and that's how I got the attention of the public. Through my clinical history at KP HealthConnect, we observed a provision of services that could not be more alien to German practice, and suddenly, participants woke up. They were glued to the screen, incredulous but fascinated. How come?

They saw that there are health centres where it’s possible to choose the doctor, to make visits only by electronic means, to contact the doctor via email. A system in which the doctor waits for the patient (Topol: the patient will see you now!), where the consultation time lasts between 15 and 20 minutes, where, if there is any doubt, the patient is referred to a specialist immediately, without derivation, without detours, without stress. I showed them how to choose, or change a GP: electronically, according to the criteria that may interest the person most, such as gender, age, language, professional interests, and previous experience with KP but also sympathy. For example, I can choose from 14 general practitioners who work at Oakland Medical Centre, the health centre closest to my workplace. (If I prefer, I can choose from many more within a radius of 30 miles or more around my residence). And to go on Kaiser Permanente is a system where my prescription - my medicines are packaged for me- is already dispatched waiting for me at the pharmacy closest to the exit of the centre.

Kaiser Permanente is a system where, as early as 2009, I could send a protected email to my doctor about any doubt after the appointment and she would respond in a few hours. Today, if I want, I can talk to my doctor or nurse through videoconference. At KP HealthConnect I find all kinds of digital support updated and based on evidence, in understandable wording, for example: an encyclopaedia of health, active life advice and healthy eating, incentivizing me through individualized achievable goals and compatible with my rhythm of life, groups of patients, etc. My audience wakes up and is outraged. If it’s possible to provide services like this, why doesn’t it work here in Germany? But as the subject of this post was what Kaiser does differently, I can’t here delve into the challenges of change in my own country. That will be the subject of a next post.

Monday, 8 January 2018

“The patient will see you now” on the subject of Eric Topol

Eric Topol, Director of Scripps Translational Science Institute, published in 2012 "The Creative Destruction of Medicine" and in 2015 "The patient will see you now. The future of medicine is in your hands." For a long time I had this last book on the waiting list and finally I could read it taking advantage of the holidays. It’s an important work, which talks about technology based on in-depth knowledge of clinical practice. It’s a literary piece, for my taste, a bit too overloaded, to the extent that, in some chapters, it’s difficult to follow the thread of the main thesis, but despite this, I have to admit that the contributions of the professor of genomics (and cardiologist) are relevant and I think they deserve to be discussed.

Monday, 1 January 2018

The induced gray areas

From scientific points of view, one tends to think that the clinical practice is binary. That is, it’s thought that the medical actions are either effective or ineffective. The reality of the practice teaches, however, that on the ground, the gray zone is much broader than one would hope because many clinical practices are neither clearly effective nor clearly ineffective. In an article in The New England Journal of Medicine, "Addressing the Challenge of Gray-Zone Medicine," Chandra and colleagues claim that due to the dazzling effects of new drugs and technologies, the gray area is expanding and therefore, these authors claim strategies to reduce the phenomenon.

Monday, 25 December 2017

More value for primary care

Xavier Bayona

A British Parliamentary report on primary health care in the National Health Service (NHS) was published at the end of April 2016. This report reflects the most relevant aspects of primary care such as the experience of care (satisfaction, accessibility, labour conflict and quality), new models of care, the construction of a new work team and financing. As you read the report, leaving aside some differences that exist between the primary care model of Great Britain and ours, the first thing that stands out is the ability they have to make a self-critical assessment and publish it. In our environment, it’s quite uncommon for self-critical assessments that engage and align professionals, managers and politicians in the improvement of services to be published.

Monday, 18 December 2017

Proximity versus quality

The proximity of the health services is a highly appreciated and defended value; not in vain regional hospitals have proliferated throughout the country as an essential instrument for territorial balance. The local organizations and the small communities have understood this and have protested fiercely against any councillor who has dared to suggest that it might be convenient to close some low-performing service. It seems generally accepted therefore; that the proximity of services is a value that favours the accessibility for dispersed populations and improves the equity of the system. However, it doesn’t escape anyone that too often, maintaining the quality of certain services when located far from the centres of reference is a challenge in itself.

This reflection has come to my mind after reading an article in the New England Journal of Medicine by Michael Porter and Thomas Lee "Why strategy matters now". One may rightly say that this source is a little far-fetched for the dilemma that I raised, especially and fortunately because the problems of our health system are very different from those of the North American system, but in return, I’ll insist that after rereading it, it seemed to me that the recipe of the two authors from Harvard can be useful in offering rational elements to the controversy around the proximity – an issue that always seems to be politicized.

Let's consider Porter&Lee’s 6 strategic proposals that can be tailored to our concerns:

1. The main objective of any strategy must be the value it brings

To give a couple of examples, in a strategy of chronic disease, community work is a value in itself; on the other hand, for the infarction code, the efficacy of clinical action is the tracer axis, so the planner must know how to balance the dispersion of the services with the excellence of the results.

2. Organization charts must be redesigned according to the needs of patients and processes

We ought to abandon the current organizational charts based on bodies, systems and levels of care and advance to multidisciplinary teams that are organized according to the needs of patients, who are responsible globally for clinical processes and that are accountable according to the value obtained ( remember that Porter’s value is the relation between clinical results and costs).

3. The portfolio of services must be adjusted to the organization’s capabilities 

In order to fulfil the main objective, hospitals must identify the services in which they are able to provide value, declining to maintain an offer that doesn’t correspond to their real possibilities or to the desired results. This adjustment is valid both for the regional hospitals’ historical difficulties in retaining talent, as well as for mid-level centres that despite all reason, focus on tertiarism as a sign of identity.

4. Clinical management units should be oriented to clinical effectiveness

The multidisciplinary teams must evolve towards "integrated" clinical management units when they have the capacity to approach a sufficient number of patients and the results obtained are good enough. In this situation, the units must be endowed with the essential resources, and even financing models based on adjusted capital or objectives, as the case may be.

5. Synergies can solve many of the current problems

To overcome the problems of excess installed capacity, duplicities, or the desire to act beyond the real possibilities, organizations must have the vision of generating synergies to solve these imbalances. Concentrating services to a single point or sharing professional teams are two strategies that, when they have been implemented rightly, yielded good results.

6. The referring hospitals must elaborate more strategies by looking at the territory

We ought to further deepen the current strategy of opening referring hospitals in the territory, with all kinds of agreements with hospitals of lower hierarchies. In the same way that it’s not good for regional hospitals to practice tertiarism, it’s also unreasonable for referring centres to dedicate their costly structures to solving case-mix typical of community centres.

It would be advisable that we take advantage of the lessons of Michael Porter and Thomas Lee in order to overcome the dilemma of proximity versus quality, generating more professional and social debate about the value of health services, since it’s pointless to have an emergency unit at every corner if we can’t support them, every day of the week and all hours of the day (and night), with qualified professionals.

Jordi Varela

Monday, 11 December 2017

8 future proposals for primary care

Primary care is the key to the good running of the health system and therefore it must be promoted, protected, improved and, above all, invest in it. Many countries are immersed in renewal processes of their primary care and, therefore, we must be attentive to the contributions we receive, especially those in the United Kingdom, where primary care is very similar to ours. In an earlier post, I reviewed a paper by the Royal College of General Practitioners that provided an insight into the role of family physicians in 2022, and in this same direction I have a report from a committee of experts of the National Health Service Primary Care Workforce Commission), which has developed a set of reform proposals aimed at strengthening the future of primary health care, broader than the previous one which was limited to a corporate vision.

Monday, 4 December 2017

We need a fish tank

Pere Vivó

The American psychologist Barry Schwartz, who can be read frequently in The New York Times or listened to in TED (Technology, Entertainment, Design) conferences, invites us to reflect on the paradox of choice. His talk begins with what he calls the "official dogma" of all Western industrial societies, which states: "If we are interested in maximizing the welfare of our citizens, the way to do so is to maximize individual freedom." The reason for this is that freedom itself is good, valuable, praiseworthy and essential for human beings: "If people have freedom, each of us can act on their own to do things that will maximize our well-being and no one will have to make decisions for us. The way to maximize freedom is to maximize choice: the more possibilities people have, the more freedom and greater well-being they will have."