Who's In Charge Here?

After President Reagan was shot in 1981, Secretary of State Al Haig famous declared, "I'm in control here," although, of course, the Constitution didn't quite see it that way.  I have to say that I feel somewhat the same way about the AMA recently taking offense at the notion that anyone other than a physician could be in charge of patient-centered care teams. 

The AMA was taking the Joint Commission to task for suggesting that other health care professionals, such as nurse practitioners, could lead patient-centered medical homes.  As Forbes had previously reported, the AMA is coming around to the idea of "team-based care" -- as long as they are the "quarterback."  In their view, any teams need to be physician-led.

Not surprisingly, the American Association of Nurse Practitioners was quick to rebut, telling Forbes it disagreed with the:

...overarching premise that physicians are best suited to lead health care teams.  Instead, we believe that team-based care is best thought of as a multi-disciplinary, non-hierarchical collaborative centered around a patient’s needs.

I've written about these inter-profession squabbles previously (Vive la Différence) and I continue to worry that they are more about status -- and money -- than they are about patients.  As I've asserted numerous times before, I believe we, the patients, need to be in charge of our own health, although we sure as hell need some good coaches and teammates.

There is some actual news for patient-centered medical homes.  A new study, reported in the Annuals of Internal Medicine, found that patients in PCMH improved quality measures in 4 of 10 measures, relative to non-PCMH patients.  The study further looked at non-PCMH patients in practices with and without EHRs, and found only slightly better results for the patients with EHRs.  The conclusion is that improvements are more about changing the culture than simply introducing health information technology like EHRs, which makes sense.

I would note that even the authors say that the PCMH quality improvement was "modest," and that another study earlier this year in JAMA found improvement in only 1 of 10 quality measures, and no impact at all on costs or utilization.  There's a lot of hopeful thinking going on with PCMH, as there is with ACOs. 

I do wonder how much of the lack of noticeable impact of EHRs has to do with the EHR limitations, or how physicians are using them (I wrote about this previously in They Shoot EHRs, Don't They?).   A study in the Journal of the American Medical Information Association found a puzzlingly (if not comically) wide variability in what physicians were using their EHRs for.  Whether that speaks to practice variations, differences in capabilities between EHRs, or disparate physician understanding of what EHRs are capable of, I don't know.  But it suggests we still have a long way to go before we maximize their use.

It may also explain why there continues to be significant uneasiness about EHRs by health care professionals.  CareCloud's Second Annual Practice Profitability Index found that 13% of practices were already looking to replace an existing EHR, while 17% reported planning to install a new EHR.  Only half of physicians with EHRs know if their EHR is certified for Meaningful Use Stage 2, so if I were them I couldn't be getting used to those stimulus payments.

Even on the institutional side, there's no love lost for their EHRs.  According to Premier's Economic Outlook, Spring 2014, HIT continues to be the area with the most capital investment, but 41% of respondents are dissatisfied with or indifferent to their current EHR.  Not exactly a ringing endorsement.

One of the long sought after features of EHRs is interoperability, so that patient information in one EHR could be shared with another provider's EHR when treating the same patient.  It's hard to be effective as a PCMH if the various providers can't share patient information.

One of the key aspects of the HITECH Act was to improve such health information exchange, but over four years and many billions of dollars later we're not much further along.  The CommonWell Health Alliance, made up of a number of key EHR vendors, did just announce that they will start rolling out some interoperability on a pilot basis later this summer.  It will impact 10,000 patients using twelve hospitals in 3 states, which is not overwhelming.

What I find particularly noteworthy about CommonWell is that one of the leading EHR market leaders -- Epic -- is not participating (their rivals Cerner and McKesson, among others, are).  Instead, Epic has created another organization -- Carequality -- to accomplish the similar goals, enlisting organizations like CVS, Optum, and Walgreens.

It's pretty symptomatic of our health care system that we can't even settle on a single organization to advance the mom-and-apple-pie goal of interoperability.  I guess both Epic and Cerner want to be the quarterback too.

A study in the American Journal of Managed Care looked at the question of what might make PCMHs successful in another way, trying to understand the impact of various features associated with PCMHs.  For example, ease of contacting the primary source of care by telephone during business hours was associated with lower total and inpatient costs (but not, oddly, with outpatient or pharmacy).  On the other hand, accessibility at night and on weekends is associated with lower outpatient & ED expenses.

Disappointingly, involving the patient in treatment option decisions did not seem to impact costs.

Based on the study, though, it does sound like telemedicine -- in its various incarnations -- should play a crucial role in making PCMHs successful.  Telemedicine is getting a lot of support from multiple fronts lately.  CMS has been deluged with letters from ACOs, telehealth vendors, and other interest groups, requesting that CMS remove some of the current restrictions on telemedicine.

Even the AMA is getting on board, recently passing a policy supporting broader use of telemedicine.  Of course, they still are holding on to the primacy of face-to-face visits and current state licensure approaches, so they're still not quite out of the 1990s mentality, but one step at a time.

In any event, I don't think I'd be in any rush to claim that my profession was the quarterback of our current health system, because it's not like we've got a Super Bowl-caliber system.  According to a new report from The Commonwealth Fund, out of 11 countries studied, the U.S. health system ranks 11th overall, pulled down by the impacts our vastly higher per capita expenditures have on the ratings.  Still, there is no aspect where we score better than 3rd (effective care).  Amazingly, we managed to rate 4th in patient-centered care, which may illustrate how low that bar is everywhere.

When you think about it, though, asking which health care professionals should lead PCMHs is a trick question.  More than anything, it reveals that the meaning of "patient-centered" still hasn't quite sunk in.  If it's truly going to be patient-centered, then surely patients should decide who is on their team, how the team is structured, how they will interact with it, and who will lead it.  Moreover, those decision are likely to change over time, especially as the patient goes through changes in their health.

For those who would argue that patients don't have the knowledge to make those kinds of decisions, I'd reply: well, whose fault is that?


Indeed, the very notion of certifying physician practices as patient-centered is quaintly old-fashioned.  Can you imagine businesses in any other industry seeking external certification that they are customer-focused?  They either are, or they go out of business -- a reality that health care providers should get ready for.

Who's in charge here?  Each of us, and we better get used to it.