Innovation, Primary Care Style

October 13, 2014
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Kids playing doctorOn a recent evening at Harvard Medical School, the Primary Care Innovation Challenge and Pitch-Off brought together <

Kids playing doctorOn a recent evening at Harvard Medical School, the Primary Care Innovation Challenge and Pitch-Off brought together six finalists, primary care luminaries and trainees, and a host of hangers-on and camp followers for a couple of hours of demos and discussions. The tenor of the evening, which was in many ways a pep rally for primary care – not that there’s anything wrong with that — was best captured by the rhetorical question posed by Asaf Bitton to the primary care practitioners and trainees in the hall, “Are you going to be a playwright or a critic?”

The hoots and hollers in response made clear that these are not your grandfather’s primary care docs. The call to action was echoed by many of the speakers, notably community organizer turned primary care physician Andrew Morris Singer and Dennis Dimitri, both advocating for, well, advocating for primary care.  Bitton’s opening also included the exhortation that proved to be predictive of the winner of the top honors from among the six pitches: Innovation in primary care is not about the technology; it needs to enable better human care.

The projects presented by the finalists ranged (in order from the techiest to the least techie) from using natural language processing of free-text notes in EHRs to improve quality metric capture, to interventions combining app-based data collection with live clinicians and care managers interacting with patients in person or remotely (Heart Failure 2.0 and Twine), to studying “positive deviance” in patients and bottling their secret sauce, to significant re-jiggering of the primary care clinical education experience in medical school (Baystate/Tufts and Beth Israel Deaconess/Harvard). (For the completists among you, here’s the full #PCC14 tweetstream.)

Here are some of the highlights:

The fact that in late 2014 an innovation showcase featured a project based on natural language processing of unstructured data in EHRs should cause, at the very least, widespread wailing, gnashing of teeth and rending of garments. I found it appalling to hear that primary care physicians couldn’t be expected to put all patient data into the structured data fields – they complain, “too much point and click,” according to Howard Haft – appalling because the EHR industry, this far into Meaningful Use, has not figured out how to make the workflow for PCPs work, so that more important patient information may be captured in structured data, or so that the EHR itself may be able to apply some NLP and logic to the free text entries in order to unlock their content for the benefit of the patient.

Twine Health, John Moore’s startup, connects patient and provider – not just the data – thus empowering patients as apprentices, taking an active role in their own care. (“No one ever gave me the chance to be in charge,” a patient using the platform said.) One arresting example of how this works: 100% of patients who were enabled to connect with case managers between appointments using the Twine Health platform were able to control their hypertension within three months. Only 25% of patients without these tools were able to control their hypertension – even after a full year. The connected patients were able to easily review side effects of their meds with their providers, who were able to start them on another med. Discontinuing meds because of side effects is apparently a key factor in low success rates in controlling hypertension.

Cole Zanetti, from Dartmouth Hitchcock, suggested that we need to keenly observe the patterns of successful behaviors among the “positive deviants,” the cohort of patients who are able to maintain good health status despite dealing with high disease severity to figure out what social determinants of health – and other factors – keep them relatively healthy, and apply that learning to the care and coaching of the less healthy. He made a compelling case for this initiative.

The winning innovation, in the end, was one of the most low-tech and perhaps the most subversive,  even though its initial roll-out has been supported by a HRSA PCRE grant. It is the Baystate Medical Center/ Tufts University School of Medicine internal medicine residency program, expanded under the grant, and also reimagined. Gina Luciano explained:

Upon graduation, residents are prepared for inpatient medicine but not for primary care (PC) careers in part due to limited ambulatory time and opportunities during training. [Under a] grant we created additional ambulatory time/experiences outside of the core ambulatory training clinic for our PC residents. We eliminated month-long inpatient electives and transformed them into year-long ambulatory continuity experiences. Residents spend 7-8 months a year in ambulatory rotations during which they participate in traditional continuity sessions as well as spending substantial time in subspecialty ambulatory electives and community advocacy projects. Residents commit to 4-5 subspecialty electives during each calendar year. Through extra ambulatory time, trainees enhance their learning of complex disease management from subspecialists, improve their ability to formulate appropriate consults and form collaborative networks with subspecialty providers.

A surgical rotation can happen in a month, because it consists of intensive, in-hospital patient encounters, with some pre-op and post-op care. Primary care – which requires long-term collaborations with other clinicians and with patients to be successful – has long been shoehorned into a training calendar that makes sense for other specialties. Now this is changing. After the grant runs out, the additional residency slots will have to be funded by the training program.

A mere schedule change winning an innovation pitch contest? You may ask why. Well, the focus on the internal medicine residency experience is in fact a big deal, given the historical emphasis placed on training physicians for careers in specialty care.

Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative (PCPCC) moderated the pitches. I asked her about the import of honoring this entry. She replied:

That the award went to a “low-tech” intervention focused on changing how we train primary care residents speaks to the importance of improving how we train the next generation of health professionals. As was stated in the IOM’s recent report on Graduate Medical Education (GME), we should be training the US physician workforce in a way that is accountable to America’s real population health needs: i.e. training physicians to treat patients and families “where they are,” in community settings, helping to empower patients and their families to deal with chronic illness and one that values all of the health care team (from physicians to medical assistants and all the professionals in-between). This is difficult to do in the current training environment which links GME dollars to inpatient hospital settings.

I also asked Marci whether the changes in medical education for students interested in primary care will have a real effect on the cost, availability and quality of that care. Her take on this:

Yes, this is an innovative challenge, and one that is sorely needed.  There is a growing body of evidence that when we treat patients and their families in advanced primary care settings (such as patient-centered medical homes) we have the capacity to improve on the care provided, as well as improve on provider and patient satisfaction.  We see cost savings, largely as a result of keeping people out of the emergency department and the hospital.  We also see improvements in overall health outcomes as a result of better managing chronic conditions in partnership with patients (see the PCPCC’s annual report from last year).  But none of this easy or simple. Asking primary care practices to transform and offer the kind of care that puts patients’ needs first requires changes in reimbursement/payment (away from fee for service and towards fee for value) and — as Gina pointed out — a focus on how and where patients really live, work, and play: in the community.

Eric Weil, Associate Chief for Clinical Affairs, General Medicine, Massachusetts General Hospital, moderated a panel discussion following the pitches. Later, he agreed that innovation is not all about tech, noting that “technology will solve some of the problem – the rest is human factors.” He ticked off three factors vital for the success of hi-tech innovations: they have to be (1) operationalized without negatively affecting workflow, (2) have broad application and (3) made affordable. Further, Weil observed that

it is changes in process and culture, changes in strategy and teaching, that will make the difference in the long run. The models in primary care and more broadly in medicine just aren’t working any more. However, the underpinning values that represent the practice of medicine remain the same. If we want to preserve the values, the models of care delivery need to change.

The hi-tech entries, in the end, were not seen as being quite as innovative as the low-tech reinvention of physician training.

What do you think?