HJNO Sep/Oct 2022

CHANGING HOW CARE IS DELIVERED 18 SEP / OCT 2022 I  HEALTHCARE JOURNAL OF NEW ORLEANS   coordinate social services, and have plenty of other knowledge domains that are well beyond my own scope of practice. I would even go so far as to attest that without tightly integrated behavioral health, achieving excellent health outcomes across a population is simply not possible. The same goes for a physical therapist trained in the McKenzie method whose eco- nomic model is no longer driven by how many physical therapy visits are generated, but rather how few does it take to resolve pain, restore function, and solve the root cause problem of the patient’s musculoskeletal problem (usually avoiding unnecessary musculoskeletal surger- ies in the process). And we now have plenty of evidence to show that achieving greater than 90% rates of hypertension control right here in Louisiana is not only possible, but actually quite easy; at least as long as a good process engineer is embedded into the care team. Skill domains, like surgical, talent is also its own topic. Suffice it to say that excellent surgi- cal outcomes are not simply the result of how many operations a surgeon has performed, but rather the end result of relentless outcome monitoring that generates constant feedback and loops of continuous clinical improvement. We know from the work of Anders Ericsson, outlined beautifully in his book, Peak: Secrets From the New Science of Expertise , that volume of surgeries performed is not nearly enough to ensure good outcomes. It takes deliber- ate practice with constant ongoing feedback, learning, and tracking of surgical outcomes to deliver truly excellent surgical results. Systems that deliver health — as opposed to traditional health systems — differentiate themselves by measuring their surgical outcomes and incor- porating feedback from those outcomes to become recognized centers of excellence, not based on brand or reputation, but rather on how selective they are with regard to operat- ing only on patients likely to benefit, how few post-operative complications develop, and on how well the patients do post-operatively. As far as technology is concerned, first at- tempts at bringing healthcare into the 21st century have been met with decidedly mixed results so far. It could even be argued that cur- rent iterations of electronic medical records are responsible for many of the woes that plague our current healthcare system, an assertion with which I would wholeheartedly agree. But I would also contend that failures to date are pri- marily because these relatively early versions of electronic medical records have neither been intentionally designed for ideal user experi- ence nor to enable and empower physicians to execute workflows that deliver the most ef- ficient and effective care. Rather, these early versions of electronic medical records have been primarily designed to facilitate coding and documentation to support transaction- based billing, where volume is king and value leaves much to be desired. However, we are also seeing technology begin to positively im- pact care. Remote patient management, for which my own health system has become a pioneer, begins to optimize talent, technology, and teamwork in novel ways, where the domain knowledge of clinical pharmacists, process engineers, data scientists, and health coaches enable superior control of chronic conditions such as diabetes and hypertension in a seam- less, frictionless, convenient, and cost-effective manner. Such remote patient management fos- ters the development of continuous connected relationships, thus enhancing experience of care for patients while saving them the time and expense of an office visit, all while simul- taneously offloading work from busy primary care clinicians and improving health outcomes. Team , the third “T” in this triumvirate, just like technology, is likewise in its infancy. Traditional healthcare business models almost exclusively favor the role of the physician because of fi- nancing mechanisms that fail to adequately financially value other very important roles. Under reinvented business models, teams of caregivers — typically coached and led by phy- sicians — will work together to help patients attain their health goals and optimal state of health, where the patient themself becomes the most important member of the team. Using a football analogy, the offensive team needs to make progress against an array of barriers, ob- stacles, and challenges — i.e., the defense — standing in the way of progress toward the goal line. The defense is composed of an array of elements that obstruct this drive to health suc- cess, such as the social determinants of health, mental health impairments, adverse childhood experiences, maladaptive coping mechanisms that underlie many unhealthy behaviors, acute injuries or illnesses, and the cumulative burden and complexity of many overlapping chronic diseases. The physician coaches and leads the team, with advanced practice providers, nurses, dietitians, behavioral therapists, phar- macists, data scientists, process engineers, physical therapists, fitness instructors, health coaches, and others, all working together as a team and doing plenty of blocking. But again, the most important member of the team is the patient, who in this analogy has the ball and needs the coordinated efforts of the entire team to make progress toward the goal line. And when the patient achieves their health- related goals, the entire team will celebrate together. When specifically considering the role of physician as coach, I particularly like this quote from Hall of Fame football player Ronnie Lott, “Great coaches lie awake at night think- ing about how to make you better. They relish creating an environment where you get more out of yourself. Coaches are like great artists, getting a stroke exactly right on a painting, ex- cept they are painting relationships. Most peo- ple don’t spend a great deal of time thinking about how they are going to make someone else better, but that’s what great coaches do.” Wouldn’t the world of healthcare be better if this mindset is how physicians saw their role in coaching patients and leading care teams? The fourth T, time , becomes a dependent variable that is a function of the mutually in- terdependent variables of talent, technology, and teamwork. In an update to the work of Østbye and Yarnall mentioned in the first ar- ticle of this series, a recently published study used very sophisticated analytical modelling to show that for a primary care physician with 2500 empaneled patients, it would now take 26.7 hours per day to adequately address all of their panel’s needs, quite literally a math- ematical impossibility. But by incorporating a team-driven approach to care, that time could be reduced to 9.3 hours per day. Unfortunately, the current relative undervaluation of primary care services afforded by traditional transac- tion-based financing constrains primary care physicians who don’t know anything other than the status quo. It doesn’t take much expertise to realize that older adults are more complex and derive significant benefit from having more time with their provider or care team. Likewise, medically and socioeconomically complex pa- tients may also require more time allocated to their care than what is afforded by prevailing