A conversation with Associate Medical Director, Massachusetts General Hospital, about incentivizing care givers to spend extra time with patients and focus on health outcomes.

Topic: Fixing healthcare.

Ron Dixon: There are a number of things that could address this problem. I think the primary one is the role of so-called primary care as the front line for healthcare delivery, really needs to be reinvented. There are several opportunities to innovate around what a so-called primary care physician does.

Unfortunately since the current model rewards physicians for actually doing things, such as procedures, as opposed to thinking about things and coordinating things, we don’t really have a workforce that is engaged in thinking innovatively about primary care and primary care delivery.

If you are able to start thinking about paying for efficiency, paying for so-called performance, paying for coordination of care and paying for a person who acts as the pinpoint for the patient, paying in a way for that relationship between that primary care provider and the patient, then you would have a way to build some efficiencies into the system.

Question: What is patient-centric care and why does it matter?

Ron Dixon: I think patient-centric care is really the ethos of primary care. We as general internists, pediatricians and family doctors are really interested in doing what’s best for the patient. I think that can become rather difficult given the pressures put upon us by folks who actually pay for the care, because sometimes they might be more interested in what is the actual cost of providing care for a population.

There are two counterintuitive forces at hand here. You want the best care for your patient who is sitting in front of you, who might be a diabetic, but then you also want the best care for the population of diabetics within a practice.

Primary care doctors don’t really have the tools to provide both, and what we end up doing is providing patient-centric care, but not in the way that we would like to do it, simply because we don’t have the time to really sit and talk with patients and think about informed decisions. We want patients to have the information and then be able to make shared decisions with the primary care doctor as the person who’s sharing that decision with the patient.

So, that would really be what patient-centric care is about. Unfortunately, in today’s environment we don’t typically have time to practice it.

Well, right now again we’re paid for what we do, which is actually perverse incentive, so it makes us do more. That’s one of the reasons I think you’re seeing the cost of healthcare rise 8% in terms of inflation per year. Now, that obviously can’t continue, and Obama has some proposals on the table to reduce that increase by 1.5% per year over the next few years.

I think however, if you start to pay for performance, pay for quality, pay for efficiency, then you eliminate these types of incentives.

If a patient has diabetes and can self manage their blood sugars, which a lot of patients do, but now we have a tool which enables the physician or the care provider to actually see those self management values and work off of those to help coach the patient as to how better manage their blood sugars and behavior, then it doesn’t matter where that management is taking place. If that management is taking place at the home, but the outcome in terms of quality is good or better than the visit-based model, then you have incentives to provide this type of care.

Question: How can we reduce costs and improve quality in healthcare?

Ron Dixon: So there are certain systems that are in the United States right now that seemed to be able to provide better value-based care. These systems that are commonly mentioned are Kaiser or Mayo Clinic or Geisinger, and what they do is that they have the ability to provide care across the continuum. So if you see someone within the system, you’re likely referred to somebody else within the system, and that information that is obtained from the first person you saw is seen by that second person, so you reduce the cost of repetition.

Additionally, those systems tend to control their administrative cost a lot tighter, and they also tend to follow certain things like formulary restrictions, and they have decision-support for their physicians in their electronic medical records that they use, and they all have the basically 100% electronic medical record utilization.

Question: What are some advantages and disadvantages of electronic medical records?

Ron Dixon: Electronic medical records are important because they allow for information sharing.

The problem with electronic medical records is that if there are a hundred different vendors and therefore a hundred different records and information cannot be shared across so-called systems. So, if you as provider X has a certain system and me as provider Y has a different system, those system don’t share information in the current state. As a result the goal of the record, in terms of making information portable and transferable is lost.

They’re very effective within the system so the tests aren’t repeated. You can see tests that were done the previous day or the previous month. They’re very good for trending tests and trending information. But the real promise of the electronic medical record is not obtained until you have a way to link different records with different information systems.

So if you would think of the electronic medical record as the car. Right now the administration is buying cars, but we need to build roads so that the cars can travel, and all that information that is obtained at a practice in Denver can be seen at a practice in Boston if the consultation has occurred in Boston. There, the promise of the records starts to come to fruition.

Additionally the record can also provide a way for the patient to have some input and access to information about their care. If the record not only becomes the EMR, the electronic medical record, but becomes a window to the personal health record, I believe that they should be one and the same, that the physician should be able to see a part of patient’s record and that the patient should have access to the same information in a view that he or she can understand. That would allow the promise of the record to really be realized, because once you start giving patients access to their information, you start empowering patients, you start empowering self management and you start really developing a shared strategy of care between the patient and the care provider.

Question: What aspects of healthcare should the US government focus on?

Ron Dixon: I think that the government should also think about investing in things that enabled patients to take better care of themselves. So, again the medical record is not enough. We need something that patients can see and we need them to access to their information, whether it’s through readily available technology like a cell phone or a laptop or a pass-key that they can go to a public library and get their information. Yes, there is a question of safety, but that has to be managed appropriately.

I think those are the types of things that the government should be spending their money on from a technological perspective. Very simple solutions that people can understand and embrace, as opposed to again whiz-bang things that people typically are not going to use.

It’s not the technology that makes the difference it’s the implementation scheme and the people behind the technology that matter.

Question: How can existing technologies be used to improve healthcare outcomes?

Ron Dixon: I think that we can use available technology to really transform how we deliver care. So for example, cell phone platforms are available for patients to manage their diabetes, to manage blood pressure. We can take examples for example from Sub-Saharan Africa where patients with malaria, instead of coming back to the clinic after they have had the test to see whether they have malaria or not, they receive an SMS to say, “Yes you have it and start this medication.” or “No you don’t. You don’t need to do anything else.”

There is an available technology, readily available. Cell phone penetration is extremely intense throughout the United States. Why not use that platform as a way to deliver care?

I think if we start thinking differently about technology; it’s not whiz bang, it’s what we use every day, and implementing that in to how we care for folks, that’s where we can start to create value and add efficiency in the system.

When I finished residency, I remember trying to innovate around how I took care of my high blood pressure patients. I started to email back and forth with the high blood pressure patients to titrate their medications, and to prevent them from coming in to have a visit with me. I thought that that would be slightly more convenient for them and really, I didn’t think it was a good use of my time to sit and talk about blood pressure when I could be handling it over a very simple media such as email.

Unfortunately, the payment system didn’t acknowledge that as a visit and my practice administrators said, “You can’t do that.”

I started to think, “Well, that doesn’t really make sense for a system. If I can’t practice in a way that makes sense for the patient and the way that make sense for me and keeps the patient happy and actually provides good quality care for the patient then what am I doing?”

In any culture, whether you have a shaman or a physician, the basis of the care is the relationship between the person delivering and providing the care, and the patient. We seem to think that technology does have some potential, a lot of potential. But technology in and of itself is not the answer.

It’s like how we use email to share stories together. I don’t share stories with people I don’t know, and usually stories that come to me from people I don’t know are spam.

If I’m going to be using available technology to manage patients it has to come from a trusted source, and it should be based in some relationship. So the work that I’m doing, for example, is really housed in that relationship between the primary care physician and the patient, but using the technology to enable that relationship.

Again for example, I have a patient who is depressed and I send him home on a medication. There is data to show that patients might be more comfortable interacting with the machine when rating their depression, as opposed to interacting with the person. That’s not to say that they prefer to receive their treatment for depression from a machine, but they might be more honest in rating their level with the machine.

Imagine if we enable patients with the tools to rate their, with their depression scores at home and then send those to the provider, and then have an assessment over video conferencing, which is shown to be effective for a lot of psychiatric issues, have that assessment and follow up or video conferencing.

So these are the ideas that I think we need to explore more in the care delivery stream.

Recorded on: May 28, 2009