It’s Not About The Box Improving Care at Group Health with People, Process and Technology

September 20, 2010

S-O-AP-AP-AP-AP: The next step in supporting pragmatic charting

Filed under: Uncategorized — Matt Handley @ 6:08 am

First cool thing at the Epic Physician Advisory Council this AM in Madison, WI – a pragmatic recognition that most “SOAP” notes (Subjective Objective Assessment Plan) aren’t really written that way.  SOAP works best for single issue visits, something that I remember fondly fron long ago, but has not been seen in my practice in what feels like years.  Most patients have multiple issues that they would like to address, and this is especially true if we are trying to be patient centered and address all of their needs at all visits.  What I have done for years is document the story – the subjective – as a whole, rather than by each individual problem.  I then document my examination – the objective – for all of the issues.  It is hard then to document one assessment and plan if there are four or five issues – for that I use a simple Epic tool to bring in all of the diagnoses I have entered, and for each one prompts me to basically document an A&P for each.

What Epic showed today is an evolution of something they call Problem Based Charting (something we are getting in our upcoming upgrade) – charting from the problem list, basically.  A great idea, but sometimes challenging if it is SOAPSOAPSOAP – doing a separate mini note for each problem.  It now supports what we do in real life – SOAPAPAPAP.    Love that Epic listens and improves the tool set – usually faster than we can all implement!

September 14, 2010

EHR Mythology

Filed under: Electronic Chart,Epic,MyGroupHealth,Policy,Quality / Affordability — Matt Handley @ 7:28 am

Just a link to a simple post that makes a lot of cogent points about EHRs, dispelling much of the misinformation out there:

EHR Mythology 101

The paragraph about why EHR implementations sometimes fail has one important omission – I believe the “group-ness” is the most important predictor for success in most any venture a medical group/delivery system undertakes.   Reading it I realize how simple  my job is compared to others – we have a great medical group that keeps the patient at the center and works to transform care.

September 9, 2010

“Lessons from the Mammography Wars”

Filed under: Evidence Based Medicine,Policy,Population management — Matt Handley @ 10:27 am

A provocative piece in the weeks NEJM that uses the recent dust up about mammography (link to the article) as a case in point has two main themes, one of which is a favorite of mine:

1.  The idea that benefit is mostly determined by baseline risk, rather than relative risk reduction

“the net benefit of all medical treatments is a continuous function of three factors: the risk of morbidity or mortality if untreated (RiskNoRx), the treatment’s relative risk reduction (RRRRx), and the treatment’s risk of harm (HarmsRx):

Net Benefit = (RiskNoRx×RRRRx) – (HarmsRx).

As the risk of no treatment (RiskNoRx) decreases, the net benefit of treatment will decrease, even if the treatment’s relative benefit (RRRRx) remains constant. Indeed, for many interventions, if the risk of no treatment is low enough (e.g., if we lower the threshold for treatment too far or if a patient’s life expectancy is relatively limited for other reasons), then the side effects and risks of treatment will dominate, and the treatment will result in net harm.7-9 Since the risk of no treatment varies dramatically among patients for almost every disease or condition, even a highly effective intervention will show a gradient of net benefit in a given population.”

2.  The provocative  idea that specialty societies and other vested interests may have important conflicts of interest that impact their recommendations:

“In any other industry, we accept the idea as natural that those providing a service or product hold their own and their shareholders’ interests as a primary objective. Why have we failed to acknowledge that the same phenomenon occurs in health care? Although it is true that individual medical providers care deeply about their patients, the guild of health care professionals — including their specialty societies — has a primary responsibility to promote its members’ interests. Now, self-interest is not in itself a bad thing; indeed, it is a force for productivity and efficiency in a well-functioning market. But it is a fool’s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone — to compete on true value when the opportunity to inflate perceived value is readily available.”

I am not sure of the feasibility of the recommendations the authors advance for how to disentangle the impact on health outcomes in absolute terms from the values we assign those differences.  Would love to hear from others about how they see this.

September 8, 2010

Moving up

Filed under: Uncategorized — Matt Handley @ 12:45 pm

Group Health will be ranked in the top 50 commercial health plans in the country this year. Number 48 out of 328 plans.   A big change from a ranking of 120th just 5 years ago.  We are happy to be improving, but a bit impatient with the pace.  The good news is that the improvement has been because of foundational investments rather than “project-itis”.  We are improving our capacity to improve rather than investing in short term solutions that don’t scale and aren’t sustainable.  Better to do first time quality than to hire a bunch of people to call people after missed opportunities.

We are hoping that our Medicare ranking will be in the top ten – we were number 11th last year.  That ranking will come out in about a month.

Rankings aren’t health care outcomes, but most of the measures do reflect clinical activities or satisfaction that matter to our patients.    We have made significant progress and built the “chassis” that will enable us to consistently surprise and delight our patients, with the patient centered medical home the shining light for us to date.  I look forward to expanding on our work to keep our patients at the center as we continue to innovate on their behalf

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