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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

“At no time in the history of medicine has the growth in knowledge been so profound… As medical science and technology have advanced at a rapid pace, however, the health care delivery system has foundered in its ability to provide consistently high quality care for all Americans…The American health care delivery system is in need of fundamental change.” Committee on Quality Health Care in America, Institute of Medicine (1).


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

This recently published Institute of Medicine report is increasing the generation-long pressure to improve American health care. It documents the current problems and argues convincingly that they are largely related to outmoded and ineffective health care delivery processes. It emphasizes that 70% of health care cost is attributable to chronic diseases, while at least 30% of this spending is wasteful and delivers no value—about $500 billion dollars per year in the US. At the same time, necessary care for chronic diseases is too often inaccessible, is not provided when indicated, or fails to provide the optimal outcome (2). An extensive patient survey performed by the Commonwealth Fund also highlights the problems many patients are experiencing with their health care (3). Our current health systems are largely designed and funded to provide episodic, acute, and more expensive inpatient care, much of which might be avoided if less expensive outpatient preventive and chronic disease care were provided reliably.

The Institute of Medicine committee concludes that providers are doing as well as can be expected until more effective health systems are designed to support dependable and coordinated chronic disease care. It also recognizes that different financial incentives for providers will be required to achieve these changes. It goes on to offer an ambitious agenda for improvement, including redesigning care processes; making effective use of information technologies; managing clinical knowledge and skills; developing effective interdisciplinary care teams; coordinating care across patient conditions, services, and settings over time; and measuring performance and outcomes for improvement and accountability. This chasm report has been characterized as “to health care what the Flexner Report was to medical education” (4). Few physicians are aware of this information.

Health care redesign offers both profound challenges and great opportunities for rheumatologists. We are providers of the outpatient chronic disease care emphasized in the chasm report. Like other specialties, our colleagues in basic and clinical research and industry have delivered magnificent new understandings and therapies for the diseases and patients we manage, and the pace of discovery will only increase. Rational evidence-based guidelines have been developed to direct optimal care. With this great promise, however, have come higher treatment costs and the prospects of greater waste and suboptimal outcomes. Our new therapies for rheumatoid arthritis are not only more expensive but must be reliably provided very early in the disease for maximum benefit (5, 6), as American College of Rheumatology (ACR) leadership has recently emphasized in Arthritis and Rheumatism (7). The severity and chronicity of the rheumatic diseases also demand carefully coordinated care over many years that our current practice processes and health systems are not delivering dependably. If we are to serve our patients' needs, we must embrace health care redesign and work more closely with other physician specialties to ensure the efficiency and effectiveness of chronic disease care, eliminate waste and duplication, improve patient adherence to long-term treatment, and provide measurable proof of optimal results. If we do these things well, our opportunities for professional satisfaction and a positive future should be excellent.

Committing to redesigning health care.

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

Meaningful health care redesign will require commitment from all those involved in US health care—providers, our medical specialty organizations, health systems, payers, and health policy makers. Physicians must begin by openly and critically examining the underperformance of our health system and acknowledging that fundamental change must occur. This self examination has barely begun (2, 8). Physicians then need to digest and commit to the Institute of Medicine agenda to close the chasm that exists between our knowledge and the care being provided, particularly for those with chronic diseases. We must recognize that this can only be achieved if academic and community-based physicians participate in and lead these efforts, and will not happen if we do not. It will require fundamental changes in what and how we teach, how we provide care, and how we manage our clinical enterprises. Change must be embraced rather than resisted.

What should rheumatologists do?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

We need to acquire the necessary skills for clinical practice redesign. Like other physicians, we are probably doing about as well as we can in caring for our patients unless we fundamentally change our clinical processes. Process redesign requires a set of skills and experiences that few of us possess yet, even though they have been used successfully in other American industries for decades (9), and are available through the Institute for Healthcare Improvement at www.IHI.org. Such skills are a requirement for changing processes real-time and eliminating unjustifiable variances, inefficiencies, and costs in complex systems like health care. Many of the process changes we need to make have not been developed or tested yet. Others that already exist have not been widely communicated. Our academic centers must become laboratories for improving delivery of care with at least the same enthusiasm as has been demonstrated for acquiring and disseminating new knowledge. Our trainees need to learn process improvement, project planning, data management, and team building skills in addition to effective care methods, core knowledge, and ethics. The ACR must broaden the scope of our continuing medical education (CME), Committee on Rheumatologic Care activities, meeting presentations, and publications to foster practice redesign among our members.

We need to rethink our role in the health care market place. Marketing and strategic planning have been a core activity of the ACR since Paulding Phelps' presidency in 1987–1988 (10). Many more Americans know what a rheumatologist is. We have successfully defined ourselves as specialists in the rheumatic diseases, and verified that “We do it better.” The Institute of Medicine report, however, suggests that better than not very well is not good enough. We must be prepared to guarantee that every rheumatic disease patient will get the best available care and verify this—“Every single one,” to borrow Dr. Don Berwick's admonition (4). We need to “Do it right.” We must also increase our market value by becoming managers of chronic rheumatic disease programs at the system and population levels and by developing win–win cooperative relationships with other providers in our care systems and communities. This will require shifting from visit-based, individualistic practice to system and population-based care. In my opinion, verifying our outcomes and expanding our care management activities provide our best opportunities for improving our futures and attracting young physicians to rheumatology. The marketplace has about had it with rising costs and underperformance in health care (11). The future will belong to those who provide the solutions.

Next, we should seize the opportunity to lead by example in health care system redesign. Rheumatologists have a tradition of leadership in the medical profession. During Dr. Bob Meenan's presidency in 1990–1991, for example, the ACR took a bold position in redesigning our relationships with industry. Some thought that setting higher ethical standards would ruin the ACR by driving away industrial support. Instead our ethics became the standard for industrial relations, strengthened the ACR, garnered expanded support from industry, and brought credit to our specialty. We now have a similar opportunity by leading in health care improvement.

Finally, I suggest that we need to redesign our health care environments to be more supportive and therapeutic, not only for our patients, but also for our trainees and successors in rheumatology, our employees, and most of all for our loved ones and ourselves (12). We are too often stressed, distracted, unhappy, and isolated in our current situations. We are working harder and harder for decreasing returns. Our business organizations are too often focused on the bottom line at the expense of clinical excellence, high professional ethics, collegiality, and a healthy existence. Our trainees finish their professional preparation in dysfunctional academic environments only to step into equally dysfunctional practice environments (13–15). We offer too little mentoring, dialogue, and emotional support to one another in what is a very demanding profession under the best of circumstances. To take better care of our patients, we need first to take better care of ourselves. Redesigning our physician culture will be a daunting, but necessary, challenge.

What can clinical process redesign accomplish in rheumatology practice?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

Successful clinical process redesign is beginning to happen within the health care industry, largely nurtured by the Institute for Healthcare Improvement and several highly integrated health systems. These early successes suggest unlimited possibilities. They demonstrate further that breakthrough changes generally occur within individual practices and systems through the efforts of process-trained physician champions and improvement teams because “All health care is local” (4). My partners and I have been into this work since the early 1990s. I hope that describing several of our projects will illustrate these process improvement methods, and how they are critical to achieving the broader aims I have outlined above.

As background, the 1980s and 1990s were decades of continuous change in the southern Wisconsin marketplace and our practice ownership. During these unsettled times, we have continued to function as a 2–4 physician consultative rheumatology practice while our business ownership has changed from independent practice to a community multispecialty group, and then to a part of the University of Wisconsin Health System. Our physician organizations have been largely preoccupied with business and governance issues while attention to improving health care delivery has lagged. We began practice redesign to cope with manpower and environmental challenges, and have expanded it to continue improving the effectiveness of our patient care. The following descriptions are of necessity brief, but the referenced publications offer greater detail and explore the implications of our work for those colleagues who wish to learn more. I feel certain that other rheumatologists must also be working to improve their practice processes, and would encourage broader sharing of these experiences.

Example 1.

We have redesigned our new patient appointment process. In most consultative office practices, a receptionist provides the next available appointment to newly referred patients. When the wait time becomes too long, we hire a new partner, close our practice, let patients and referring physicians accept the wait or look elsewhere, and/or overload our full days with urgent cases brokered by our referring colleagues. Three years ago, our practice implemented physician preappointment management for all new patients after losing 2 of our 4 partners. One of us reviews each referred patient's records before we provide an appointment. We have continuously monitored and refined this process change. Our published experience demonstrates that we did not need to see 40% of referrals to ensure their optimal care, as summarized in Table 1 (16). These patients were already receiving such care for simple, self limited musculoskeletal disorders but were seeking assurance through consultation, should have been referred to another specialty, or did not need care at all (lawyer referrals and misinterpreted lab tests, as examples). We always discuss these cases with the referring physician before recommending an alternative to consultation. If there is any doubt, we see the patient. We have learned that we can make accurate decisions, that patients continuing with their primary physicians do well, and that our assumptions about what our referring colleagues and patients want from us were often incorrect.

Table 1. Results from the first 6 months of preappointment management
 n
New patient referrals279
Patients seen165
Patients not seen, total104
 Consultation not required51
 Other consultation more appropriate31
 Appointment not appropriate22

We now have same-day access for urgent cases, a short wait for other consultations, complete information at the time of consultation, highly satisfied patients and staff, better communication with referring physicians, and 75% of our previous manpower doing all the necessary work. Each of our physicians spends 30–60 minutes/week to accomplish this. For patients we do see, this time is compensated as part of our consult coding. For those we do not see, it is uncompensated, but should be. We have also used preappointment management in cooperation with our spine surgeon to implement a successful interdisciplinary spine care program (17), and our otolaryngology practice has adapted it to great advantage. After reducing low value care, we have turned our attention to expanding other higher value care, including an osteoporosis specialty service (see next example), an interdisciplinary hand clinic with our orthopedic colleagues, and more clinical research. Our experience demonstrates the benefits of improving patient flow management and begs the question of how many rheumatologists are really needed in the US if we manage the referral interface more effectively. Better us than the insurance companies.

Example 2.

Our practice provides dual-energy x-ray absorptiometry (DEXA), osteoporosis consultation, and osteoporosis CME to our health care system. After 15 years of doing this, we began collecting performance data within our system that showed poor osteoporosis care for most patients at high risk for fractures, as summarized in Table 2 (18, 19). Motivated by these data, we have established an osteoporosis improvement project in our health system, and are participating in broader initiatives to improve osteoporosis care nationally. We have developed a rheumatology-based osteoporosis specialty service after convincing our primary care and orthopedic colleagues that this departure from traditional processes is needed to assure effective care for the patient population we serve. We have figured out how to identify the populations of high risk patients from billing data rather than relying on physician visits alone, and have been provided the additional staff, space, and DEXA capacity for this program by making the business case for the increased profit to be gained from expanding appropriate care. This experience illustrates a shift to population-based care and the importance of process planning, pilot trials, and performance data monitoring to successful change. Osteoporosis continues to be a growth industry for rheumatology, but this won't happen unless we redesign care to capture and effectively manage our high risk patient populations.

Table 2. Osteoporosis management of high risk patients*
  • *

    University of Wisconsin health data. DEXA = dual-energy x-ray absorptiometry.

5% of hip fracture patients in 1999 evaluated and treated for osteoporosis
30% of women older than 65 years have had a DEXA
14% of patients taking long-term glucocorticoids (20% of women older than 45 years) are taking a bisphosphonate

Example 3.

We started using a health assessment questionnaire (HAQ) just 18 months ago. This simple instrument has yet to be incorporated into most rheumatology practices in spite of 25 years of pioneering and documentation of effectiveness by Drs. Jim Fries, Bob Meenan, Fred Wolfe, and Ted Pincus (20). The use of HAQs in more recent clinical drug studies has further verified their usefulness in measuring patients' clinical status. The HAQ saves us visit time, focuses our effort on our individual patient's most important needs, helps us measure disease status and the impacts of therapies over time, and helps to document a higher level of service. We are converts! Our patients love it. The prospects for computerizing flow graphs for this information, using HAQs to identify those patients in our population who need extra attention, supporting achievement of measurable outcomes, and proving the effectiveness of our management are truly exciting.

Example 4.

We are using electronic medical records, e-mail communication with other physicians, Uptodate (Uptodate, Inc., Wellesley, MA), and other computer-based practice aids. In addition, we are adopting and developing decision support software to register and manage our chronic disease patients, including those with inflammatory arthritis, osteoporosis, and long-term glucocorticoid users. Decision support research has shown clearly that we are unable to provide reliable care over time to patient populations with office visits and paper records alone (21). I find it incomprehensible that my dentist and veterinarian both have more effective electronic data systems than I do!

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES

The conventional view of rheumatology's future predicts that our manpower, resources, and rewards for our work will continue to decrease during the coming decades, even as our capabilities and the need for our services increase. We should reexamine this view, first because our potential value in the health care marketplace predicts more positive possibilities, and second because maintaining a fatalistic perspective will only create a self fulfilling prophecy. Experience from other industries shows that when organizations are in trouble, some individuals will cling to the status quo and go down with the ship; others will drop out or go elsewhere and too often rediscover similar problems; fewer still will embrace the positive and fundamental changes required for a successful future (22). The commitment my partners and I have made to redesign our practice and expand our disease management activities is improving our value and profitability, elevating our sense of professionalism, improving our environment and our lives, and spreading to other practices within our health system. I believe this approach will draw trust, revenues, and manpower to rheumatology and provide the ACR, rheumatic disease patients, and us with our best opportunity for a successful future.

REFERENCES

  1. Top of page
  2. Abstract
  3. Introduction
  4. Committing to redesigning health care.
  5. What should rheumatologists do?
  6. What can clinical process redesign accomplish in rheumatology practice?
  7. Conclusion
  8. REFERENCES