Ch-ch-ch-changes

(Turn and face the strain)…

If ever there was a song describing medicine today, David Bowie captured it in a single lyric: Changes. Some prefer revolution, some say 'Valley of Death,' others simply call it the future. Whatever your choice from the thesaurus, medicine today looks different than yesterday—and will be altered again when you wake up tomorrow.

What can you do to make sure you come out on top when the world of health care finally stops spinning?

Choose One from Column A, One from Column B

The increasing demand for efficiency, accountability, control of health care costs, data management, performance-based pay, and standardization of services signals great changes ahead for medical practices. And know that we are not alone in this: for example, exchange the term 'health care' for 'education' and you can instantly understand what is driving the current upheaval in our schools these days. (Give yourself an A on that pop quiz.)

Physicians who welcome the challenge and develop the nonclinical and leadership skills that the times require will help write their future. But how do you get there?

Actually, you may want to stop for a bite to noodle it over. Even though physicians don't like to think that what they do each day has anything in common with serving up meals at a restaurant chain, Atul Gawande, MD, a surgeon at Brigham and Women's Hospital in Boston, suggested exactly that in an article in The New Yorker last year. While medicine tries to deliver many services to masses of people at a reasonable cost and with consistent quality every day—somewhat like a successful restaurant chain—it generally fails to do so. "Our costs are soaring, the service is typically mediocre, and the quality is unreliable," Dr. Gawande wrote.

In what is clearly an unsettling comparison of medicine with The Cheesecake Factory, he noted that the big chain has condensed its institutional knowledge into precise instructions and objectives, including leadership development and using technology to increase its efficiency.

Compare that to medicine, where the "biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results.… Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital," Dr. Gawande said. "We've let health care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous."

Kind of hard to swallow….

The First Step is the Hardest

Thomas H. Lee, MD, president of Partners Healthcare System and CEO of Partners Community Health Care in Boston, has seen his own health care system institute some major changes in delivery systems that pulled them out of the Valley of Death and onto higher ground. Step one up the mountain: Accept that changes are needed and develop leadership to make the changes happen. To do so, Dr. Lee noted, physicians should undertake their appropriate role as leaders of change, not as resistance fighters. "If they try to assume the role of victim, I'm afraid they are going to find that they are not sympathetic characters.… Their organizing principle cannot be 'I don't want my income to go down.' That can't be the goal. The organizing principle has got to be trying to meet the needs of patients as efficiently as possible," Dr. Lee said.

That means physician leaders will have to build a sense of shared vision, helping their colleagues understand they are all in it together. Next, physician leaders develop and lead systems of care that produce better values of health care for patients in demonstrable ways. "And they have to be engaging in contracts where there is an explicit motivation for them to provide better outcomes and to do so more efficiently," Dr. Lee stressed. "If you're not in an organization that is actively pursuing that goal and making it a business strategy, you have to wonder whether you are really doing it or just sort of dabbling."

Getting there requires a 100% effort. Well, it really takes about 130%: Demands in the new world of medicine may require that physician leaders spend at least 30% of additional time on administrative duties beyond the 100% of time they spend as clinicians. To make the math add up correctly, physicians need to learn from successful businesses that budget at least 10–15% of their gross income on research and development, which usually gets a big goose egg from physician groups, noted Peter L. Duffy, MD, director of cardiovascular quality at Reid Heart Center in Pinehurst, North Carolina.

But this may be the time to put more funds into education, training, and leadership development, Dr. Duffy said during a presentation at the recent ACC-sponsored Cardiovascular Summit: Solutions for Thriving in a Time of Change.

Leadership development acknowledges that medicine has moved on from the days when a business manager and a head nurse ran smaller practices. Health care needs well-trained physician leaders but being a respected clinical leader doesn't necessarily translate to being an overall physician leader. "I could be the best guy in the cath lab but I may not be the best leader. Those that have pursued additional training do well with it.… They are learning better communication techniques and certainly the language of business," explained Suzette Jaskie, president and CEO of MedAxiom Consulting in Neptune Beach, Florida. MedAxiom is a subscription-based network of more than 300 US cardiology practices that share strategies and experiences to become more effective and efficient.

"We have spent a lot of years since health care reform with people being depressed and wringing their hands. I think it's time to be excited about operating in a new future," she said. "Physicians have more opportunity to lead us into the future than they ever had before. I tell practitioners to be bullish about the future. Enough with being victimized."

The 'I' in Team? Interdisciplinary

So what other skills should physicians possess to thrive in this period of great change? Although many physicians have earned MBAs or degrees in economics, today's challenges may be best met with a different expertise. "It is important today to learn the nonclinical skills that will make you effective," Pamela S. Douglas, MD, Ursula Geller Professor of Research Cardiovascular Diseases at Duke University Medical Center, said at the Cardiovascular Summit. "It's those skills that will allow you to deal with all the changes in our health care environment."

In fact, one of the top strategies that clinicians may need to develop, if they haven't already, is how to work in teams that are focused on quality and outcome. "We have to figure out how to work together in groups to improve value. If we don't, things will be miserable," Dr. Lee said.

Working together means organizing into interdisciplinary teams that are focused on certain conditions, such as ACS, diabetes, or stroke. To operate efficiently and effectively, these teams will need to develop "dashboards" that direct patient interactions, "pause points" in patient care that define what steps are needed when in patient care, and checklists with items chosen because they can be expected to lead to better outcomes, greater efficiency, or both, Dr. Lee explained in a recent article in The New England Journal of Medicine.

"Who should be responsible if a patient with heart failure is not seen within 7 days after discharge? The hospital? The primary care physician? The specialist? The answer, of course, is 'all of the above,'" Dr. Lee advised.

Survival of the Biggest?

Doctors in small groups may be able to meet the demand for greater data transparency and efficiency, but being part of a larger group will make it much easier for them to do so, to add value beyond merely providing office visits and exercise tests, Dr. Lee said. In other words, running a mom-and-pop-size medical practice may work in the furthest reaches of rural America, but the growing drumbeats for better efficiencies and outcomes—both health-related and financial—are driving the move toward soloists consolidating into larger and larger bands to make sweeter music.

Joining with larger practices and becoming part of larger teams to run more efficient health care systems are the paths to the future to improve quality and slow spending, noted Dr. Lee. "Small practices or solo practices will be at a disadvantage if they don't. I do think that we are all going to look back on this time and ask the question about whether we adjusted too fast or too slow. Understanding that we will probably feel some remorse a decade or two down the line, that should be some incentive to try to be more forward looking and open to change, painful as it might be for very hardworking people," he said.

P is for Patient, Q is for Quality

When you ask patients about the outcomes they most desire in health care reform, they want to be kept out of the hospital and out of a sick bed. That patient focus on quality of life should be the mantra for physicians as well. "We encourage patients to get hysterical about certain things, such as their LDL, whereas their real goal is to keep out of the hospital. Shifting what we're actually trying to control to that very challenging set of measures of things that actually matter to patients is a huge leap forward for clinicians," Dr. Lee said.

What makes that leap longer, noted Ms. Jaskie, is that physicians have traditionally practiced medicine based on individual performance rather than measuring themselves against clinical standards. The latter may only mean a patient was having a good day; whereas standards become norms and help ensure data transparency. "Learning how to be more efficient has meant subspecialization in most practices; learning how to optimize processes, people and IT; and bringing a financial context into the conversation—being measured against quality relative to cost," she explained.

Clinicians deliver excellent visits, procedures, and tests. "They do a terrific job on people right in front of them, doing what they are paid to do," Dr. Lee said. But because they haven't been paid to measure outcomes, outcomes have not been measured.

Step by Step: Dancing to the Standards

To effectively measure outcomes, all team members not only need to understand the clinical standards but also agree on procedures that can help them meet those standards time after time. You could think of it as, well, standardization, sort of what The Cheesecake Factory does with every order of hibachi steak, according to Dr. Gawande. The line cooks understand what the finished product should be.

It's not medicine, but it's a step-by-step recipe for success that works every time at the restaurant.

Richard M.J. Bohmer, MB, ChB, MPH, and Dr. Lee looked at this notion of standardization of processes in medicine in a 2009 article in The New England Journal of Medicine. Shifting medicine to an outcomes-oriented organization, they warned, may mean that individual physician autonomy becomes somewhat limited, particularly in "circumstances in which the routine that generates a good outcome is well known." When there is no known routine, physicians will have to come up with the knowledge needed to develop one. In other words, physicians will need to wear two hats: one clinical and one managerial, "in which they help to design, oversee, and improve systems of care."

Ms. Jaskie has danced the standardization samba with practices transitioning to electronic medical records. In one practice, for example, the 30 doctors each had a different way of rooming a patient: some took blood pressure immediately, others about 5 minutes later; some started with the right arm, others with the left arm; some wanted the patient to stand, others wanted the patient to sit.

Coming up with a standardized rooming process for this practice took about 6 months, she said. All of the physicians had trained at different places and at different times, and each developed personal standards relative to their training. "To get physicians in a room and to sort out clinically what really has value means they have to sort through all the reasons why they do what they do," she said.

"When physicians are able to create the clinical standard from an operations perspective, then we can optimize people, train people, and leverage IT to work around their standards," Ms. Jaskie explained. "If they don't create the standard, then we can't be efficient."

View from the Mountaintop

The process starts with what Ms. Jaskie calls the "operating lens" that a practice chooses for its operation. By mapping step by step what the practice and the clinicians do and why they do it, the chosen lens provides the practice or health care system a focused framework for reorganization.

When those agreed-upon processes are linked with today's information systems, medical practices can begin to see the progress and changes that the times demand. Practices and systems benefit from younger people bringing in essential innovation. "They are thrilled by the chance to use their creativity to do things differently, such as organizing teams to follow patients with heart failure," Dr. Lee said. They are developing iPad applications to help patients track and report outcomes, and they are inventing methods to monitor procedures, identify and reduce those that are overused, and, in turn, decrease health care costs.

Innovation extends to prevention, such as enhanced email and online support from clinicians and smartphone apps that can coach patients to manage their chronic disease and stay out of the emergency room or hospital. Efficient, affordable, and accountable health care means moving bullishly into the era of bigger health care systems that monitor detailed performance metrics to improve the experience of patients. "Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients' experience counts for more," Dr. Gawande said.

Conquering the climb out of the Valley of Death means committing the time to initiate and institutionalize appropriate changes, which isn't easy, Dr. Lee said. "We have, however, found the time to do lots of things, some reimbursed and some not reimbursed. Moving forward, these are going to be stay-in-business type decisions."

Some organizations and people, he added, will obstinately remain planted in the Valley, doing things the same way, never finding the key to unlock the exit door. Others will take the opposite tack, firing all their creative cylinders to race to the top through efficiency—and prospering at the peak via a payment model that rewards them for effective changes made.

Bottom line? "No one should assume this is going to be easy," Dr. Lee stressed, but growing numbers of clinicians "are going to find ways to be creative and to derive satisfaction from responding to the challenges and opportunities."

Will you be joining them at the summit?—by Kathy Holliman

Keywords: Patient Care, Health Care Reform, Chronic Disease, Physicians, Primary Care, Blood Pressure, Health Care Costs, Electronic Health Records, Quality of Life, Delivery of Health Care, Heart Failure, Medicine, Cardiovascular Diseases, Leadership

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