How do we change the way we think about taking care of patients, particularly when it comes to not the individual patient sitting in front of us, but a whole population of patients just like them (or somewhat like them)?
In our practice, we have been struggling with how to best do population health, trying to find the best ways to systematically address the barriers to health that all of our patients have.
On an individual patient-by-patient basis, I think most providers would say that yes, for the patient sitting in front of them in the office today, they’re doing the best they can, trying to keep up with all the things that need to be done for each patient.
But then, if you asked them how their practice is doing as a whole taking care of the needs of entire populations of patients, such as keeping health maintenance items updated, disease-specific metrics, vaccines, health care proxies, and an ever-increasing list of other interventions, I think we’d all agree that try as we might, we’re probably not doing all we can.
A numbers game
I’ve written before about how hard it is to keep up with the health maintenance items in our electronic health record. Documenting a long list of items that the patient is due for, based on their age, gender, or comorbid conditions, can be a daunting task.
It’s hard enough actually doing these things, remembering to do them all, encouraging our patients to get them done, ordering them in the system, having that lead to an appointment or a vaccine or an imaging test, but then to try and remember to go back and click the box that said they had their shingles vaccine done at their local pharmacy, or their mammogram done at an outside facility is oftentimes just too much.
When we look at the numbers, it often seems like we as a practice are not doing all that well.
Luckily, for the most part, when our patients do many of these interventions within our own institution, the electronic health record has this right, and successfully captures much of this and puts it in the right place.
But for a lot of our patients, they get a lot of the stuff done outside of our home institution, be it a mammogram, a flu shot or shingles vaccine that, due to either convenience or insurance, they’ve chosen to do elsewhere. Then the provider is left to do the work of hunting it down, ensuring that it was done, and getting those boxes all clicked.
So when we run our population health reports, I don’t think they really reflect the truth of how well we are taking care of our populations. Nonetheless, we are currently undertaking some interventions to try to improve how we deal with population health, and ensure patients get all the things done that we think are right for them.
Labor-intensive interventions
Take mammography, for instance. Recently, we targeted Medicare patients in our health system’s accountable care organization (ACO) by sending letters to all patients who didn’t have documentation in the electronic health record of a timely mammogram.
Unfortunately, this led to a lot of phone calls back from patients asking why they were being sent this letter, since they had clearly told their doctor that they never wanted to do this test again, or they’d had a bilateral mastectomy for breast cancer and were never going to have one again.
We’ve tried other interventions, such as focusing efforts on patients from various underserved populations who didn’t have evidence of mammography in the system, and reaching out to them with care navigators to discuss getting the test done. Some of this went really well, but all of these solutions are incredibly labor-intensive, and require a lot of hard work from a lot of staff who don’t have much free time.
Often, as my patients and I wrap up their visits, I like to go through their health maintenance items just to make sure we got everything covered, and I’ll ask them whether they have seen their gynecologist, did they get their flu shot in the community, and when was their last colonoscopy. This is the stuff I document in plain old-fashioned typed-out text in the bottom of my note.
Wouldn’t it be great if the system was smart enough to read my note and know what I’d written (and what it meant), and use that to say that “Yes, this patient had their mammogram done earlier this year, so we’re all okay?”
Hope for the future
In the future, maybe some sort of artificial intelligence and natural language processing will be able to crawl through our notes, abstract this crucial information, and then maybe even go further by crawling down the electronic network of information out there in the world and find that mammogram report uploaded on some outside radiology facility’s memory banks, and pull it into my system.
I recognize that this will always have limitations, but if we learn to format this stuff the right way within our charts, even if it’s free-text typing, then maybe, just maybe, this task will become even easier as we move forward.
Ultimately, each and every one of the steps we take to ensure the health of our patients requires a shared decision-making conversation about what a patient wants to do and what we think is right.
Take, for instance, a patient we saw just recently. The patient was well beyond the age when they should have started getting colon cancer screening. Noting that the patient hadn’t had any such screening, the resident discussed this with the patient and ended up ordering a colonoscopy.
When we looked back through the patient’s chart at the end of the day, we found that the patient had been referred for a colonoscopy last year. And the year before. And the year before that. And so on back over a decade.
As we think about how to tackle gaps in care and better take care of populations of patients, we need to not only think about making sure the boxes are checked correctly, but that appropriate patients are offered the best information to get them the care they need, and that the system is there to support them.
Although the future will most certainly bring intelligent systems to help us do this stuff better, we’re always going to need people to do legwork, to track down that outside imaging report in those old records or the pharmacy vaccine receipt, and we are going to need people making phone calls and helping patients overcome transportation barriers and cultural beliefs about why they should or should not get a thing done.
And always, in the end, we have to remember that a population of patients is made up of many patients that may be in so many ways just like the one sitting here in front of us today, but each one is so very much an individual with different values, needs, and choices to make.
A population made up of many individuals.
One for all, all for one.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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