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For many years, I was focused on health policy and I actually worked
with the Clinton administration to try to pass health reform.
And when a colleague of mine came and said,
what's the next important thing you want to work on?
What are the big problems?
I said, clearly, care coordination is the big problem.
And so I took it on and started doing work around it and, like everybody else,
I came across my own horror story, really, my father got ill,
he spent more time than we would have liked in the medical care system,
going from doctor to doctor, going from hospital to hospital, my siblings and
I did our very best to keep a notebook with all the notes.
And we would transmit the information as best we could from doctor to doctor.
And ultimately,
I say that my father passed away because of a care coordination failure.
So the problem that I care a lot about and have focused a great deal of my research
on recently has been care coordination, I call it integrated care.
The reason I call it integrated care is because I feel like it goes beyond just
mere coordination.
I really feel like integration is something
more holistic because it accounts for
all of the customization that's required to care for a particular patient.
So it is the communication and it is the coordination but
it's done on behalf of each individual patient according to the patient's needs.
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Traditionally, the system has grown up in silos so
doctors have trained alone nurses have chained separately.
They're trained to optimise what it is they do not so much to communicate with
each other and it's the between the cracks where the problems occur.
So information doesn't transmit.
When information doesn't transmit, if a patient's been in a hospital, and
then they go home, if that information about the hospitalization doesn't get back
to the primary care provider, that patient is at risk for not having a follow-up
appointment is much more likely to get readmitted back to the hospital.
The primary care physician refers a patient out for a screening exam.
But doesn't get the information about the result of that exam back that patient is
at risk for not having the appropriate follow up.
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We have a traditional payment system in the US were predominantly,
providers are still paid on a fee for service basis.
That means, if they perform a service, they get a fee for that service.
That encourages providers to provide more services, it does not encourage providers
to spend time coordinating care on behalf of their patients.
And so, there are efforts to reform that payment systems, in ways that
align the incentives with the kinds of initiatives that I've been talking about.
So rather than a strict fee for service, there are experiments around, for
example, Accountable Care Organizations and some Accountable Care Organizations
assume risk for either physician services or for all services.
And you have more of an incentive to try and create the kinds of processes and
programs that I've been describing that allow the providers to attend to
the coordination needs of those patients.
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Over decades, the VA has been leader in terms of quality and
efficiency of the care that they deliver on behalf of the veterans,
and the reason that they have been so far ahead of the rest of the system in the US
is because it's an integrated delivery system.
It's of one of the very few we have examples of in the United States.
The primary doctors and the specialist and the hospitals,
they're all part of the same system.
And they have four decades shared an electronic medical record system,
which means that as a primary care doctor, I could see what the specialist has done
on behalf of my patient and I can follow up in a way that in the private healthcare
system, we very often don't have the ability to do.
So for those reasons, they have had great advantages to be able to deliver high
quality and more integrated care.
And they have had their share of visionary leaders who've really prioritized
quality and coordination and patient centeredness.
And when you have that along with caring for
your patient, the combination of those things are pretty powerful.
Everybody really wants to do their best.
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They're instituting a new program called their Care Coordination and
Integrated Case Management Program.
They're creating hierarchical levels of intervention.
So for the very most complex patients, they have one set of processes.
So they're actually assigning a care coordinator to work with that patient and
the family.
To go with that patient to their different visits, and
to make sure that the information flows back to their primary care doctor.
And for the next swath of patients, still complex, but
a little bit less so, they have another level of intervention, and
then for a level down from there, third level of intervention.
So they're trying to assign their resources according to
the needs of the patient.
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We've gone into practice sites to try to understand what they're doing,
what tools they're using to try to tease out what's a better practice than then
not a better practice.
And interestingly, when we did this initially over 150 practice sites,
we couldn't discern anything that was differentiating them,
the things that we expected would be differentiating whether they had
a shared electronic medical record system, whether they were multidisciplinary,
whether they were sophisticated in terms of their IT, or
sophisticated in terms of their care management processes.
None of those things systematically related to improving integration for
their patients.
And so, we went to organizations that the patients suggested were
high-performing versus low-performing, to try to tease out some of the differences.
And what we finally discerned kind of at its essence
was that organizations could take whatever resources they had available,
whether it be a sophisticated electronic medical record system, or whether it was
a kind of individual resource like a care management person within the organization.
So long as they took those resources and
really focused their attention on the goal which was to integrate care for
the patients, there were lots of different paths to getting there.
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If somebody says I want to start, where should I start, I always tell them to
measure first to find out where their unique strengths are and
where their unique challenges are.
And once they have that, they can really create for
themselves a roadmap that I think makes sense because
every organization is going to be a little bit different that way.
What we're looking at is, is trying to get people to make incremental improvement.
There's a tremendous amount of focus on this country.
The next great drug or the next great device and instead my research
focus is on kind of the next great improvement in ways that we can transmit
information and coordinate care because if we don't do that,
then the the drug is not going to produce the benefit that we need it to produce.
If we have a procedure because it's a great new procedure that we're able to do
with some sort of automated robotic way of doing it, that's tremendous, but if there
isn't appropriate follow up for that patient, they're not going to benefit from
having that procedure, and they can end up either worse of or back into the hospital.
And so, in order to make them work well, we need cultures within organizations,
and people within organizations that prioritize their combinations.
So it's going to be very incremental, but
if we could actually move the ball down the field,
we'd be saving life after life after life, it would be a game changer.
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