The Changing Rheumatology Practice

J. Timothy Harrington, MD, University of Wisconsin School of Medicine and Public Health, Madison, WI. Moderated by Michael J. Maricic, MD, Catalina Pointe Rheumatology

Identfibroifying the readiness of your practice to transform is the first step in changing with the times, began Dr. Harringtion, noting that this assumes few are ready for the changes that will be necessary in the next few years or decade, coming internally among rheumatologists for improving care and from external health system stakeholders (seen in the "feeding frenzy" in Washington).

Identifying the core concept of models for redesigning a physician practice is the next step, said Haringtion. He noted that stating this assumes that no single model will prove to be ideal, as fundamentally, all healthcare is local. The speaker explained that he "can't solve your problems, but can give thoughts and themes and point you toward methodologies."

The need to discuss the pros and cons of practice redesign assumes that accomplishing redesign is a matter of survival, not an option, explained the presenter. He added that, soon, physicians will be paid as part of a team, not as individuals. Currently, the healthcare system fosters a single specialty, individualistic provider, making for a competitive, inefficient, fee-for-service system. In the future, said Harrington, there will be system-based, interdisciplinary care teams with standardized, defined roles; the system will be patient-centered, cooperative, and efficient, and physicians will be paid for outcomes and based on episodes of care.

The challenges facing rheumatologists, explained Harrington, are that "we are not delivering optimal outcomes with the current delivery of care and disease management processes; payment will soon require verifying processes and outcomes (P4P); practice revenues are not adequate, may decrease further, and will be designed around systems and episodes of care; manpower will be inadequate to provide necessary care as we do it now; arthritis care is not a high priority in most health systems, except for rheumatic disease patients and rheumatologists; and the health systems in which we function are producing poor outcomes with high waste at a high cost (that's what has Washington stirred up)."

Healthcare needs to become a team game, continued Harrington, adding that physcians are not taught this. Practice processes are highly individualistic, variable, and inefficient, and health systems are fragmented and chaotic, he added, which all leads to waste. "If healthcare is to improve, physicians need to do the work," he stated.

The presentation continued, with Harrington quoting Eric Newman, MD, who said "You don't understand what you don't measure, and we don't." He added that most measurements used in rheumatology require complex equations that can't be used at the point of care.

High priority improvement processes were next on the agenda, with Harrington explaining that they require physician-nurse-patient teams and the redefining of who does what. "We have part-time patients; we should have part-time physicians," he said. Teaming up of rheumatologists allows them to collectively cover a practice, with the patient being a part of, for example, team A.

"We have to organize our work," continued Harrington, "with an arthritis established patient visit process. We have to decide what the work is and who is going to do what. There has been a shift from what the physician does to what the patient does, and nurses should do more than just take blood pressure... This shifts the work off the physician's plate and allows them to spend time and analyze with the patient, discussing care with the patient and focusing on patient education." Rheumatologists should also standardize the information they take with forms, said the speaker, who added that patient-generated information is key. "You can't afford to not do this," he stated.

Rheumatoid arthritis treatment decisions were the focus of the next few minutes of the presentation. Harrington said they should be based on the following equation:

Patient-generated Global Arthritis Score and AM stiffness + swollen joints and joint damage + joint image --> physician global estimate of disease activity plus risk/benefit assessment including safety monitoring + patient preference --> treatment decisions.

All the points made thus far in the presentation, said Harrington, are designed to improve the physician's focus and efficiency and free physicians to be problem solvers ("that's what we're trained to do," he noted); minimize physician visits for established patients with controlled disease to create access for new and established patients with active problems; and reduce physician time per visits-standardization (doing work the same way each time) promotes high accuracy and efficiency. "It's amazingly comforting" to follow standardized procedures he explained, adding that it allows him to see more patients and not go home as tired. "With no rules, everything is an exception," he said.

Harrington next discussed managing new patient referrals to define the scope of practice and rationalize patient flow. The traditional way is that the high-risk patient goes to primary care provider, then the specialist, and then back and forth, he explained. The problems with this include that it is visit dependent, patient driven, and highly variable; allows for duplication of waste and cost; consists of poorly defined processes and provider roles; and allows for a population that is at risk to not be identified properly.

before an appointment is scheduled

Pre-appointment management is key, said the speaker, and should include a "review of prior medical records and other pertinent info by the consultant physicians in order to determine the most appropriate care plan for each patient."

The critical questions in regards to healthcare improvement, according to Harrington, are as follows:

• What to do? (research and guidelines)
• Who to do it? (planning, algorithms, PDSA)
• Who will do it? (provider roles defined and communication)
• How well does it work? (outcomes measures)
• Who will pay for it (???, P4P - what has Washington stirred)

"Nurse coordination for chronic disease care is an indispensible tool that we have to use," added Harrington. "Nurses love doing this stuff; physicians hate it."

Also important is smart scheduling, according to the presenter, who offered the following example of poor versus intelligent scheduling in rheumatology:

Poor Intelligent

8:00AM (consult) 9:00AM (follow-up visit)

9:00AM (consult) 9:15AM (follow-up visit)

10:00AM (follow-up visit) 9:30AM (follow-up visit)

10:30AM (follow-up visit) 9:45AM (follow-up visit)

11:00 (follow-up visit) 10:15AM (consult or 3 follow-up visits)

11:30 (follow-up visit) 11:00AM (consult or 3 follow-up visits)

11:45AM add on

Harrington moved on, quoting Morris AH from a 2000 issue of the Annals of Internal Medicine: "Humans have a limited ability to incorporate information in decision making" and "Unaided human decision makers do not posses the consistency of behavior or the accuracy of perception necessary for consistent delivery of recommended therapies:" Harrington added that "it's like texting and driving; nobody can do that, but people do it. We're like that as rheumatologists."

Process management software was the next focus for Harrington, who said such software incorporates guidelines for optimal diagnosis and treatment into a standardized task algorithm; enables healthcare providers to build registries by disease and identify high-risk patients; follows step-by-step intervention plans for diagnosis, treatment, and education; fosters communication with patients and treating physicians; organizes clinical work to assure necessary tasks get done reliably; and helps with the monitoring and improvement of healthcare management.

Harrington next focused on the elements of an optimal clinical environment. He said these include business management, clinical data repository, task management programs for acute and chronic diseases (individual patients, disease populations), outcomes measurement and documentation programs, and medical knowledge programs. Focusing on this last item, Harrington added that all physicians have access to these but that they are too frequently used. "We still think we have to memorize this stuff, but the information is changing too quickly and it's overwhelming," he noted.

Chronic disease population registries are critical to changing healthcare explained the presenter. He added that they need to be embedded at the practice level and can be as simple as an Excel spreadsheet and populated from billing data.

Achieving breakthrough improvement in complex systems requires work and skillfull use of continuous improvement methods, continued Harrington, noting that CQI (continuous quality improvement) and PDSA (plan, do, study, act) methods work best. PDSA, he said, is the preferred method for improving complex systems, completed through small pilot tests of change. "They don't mess up the work flow of day-to-day practice," he said. "Normally, physicians go home pissed off on Friday, get rest on Saturday, think of new way to do things on Sunday, and then go in Monday telling staff of change," and the staff get upset and overwhelmed with the change, he said.

The bottom line, concluded Harrington is "Patients first." He saw this clearly at the Cleveland Clinic, where there are flat screens hanging from the ceiling that every 30 seconds display "Patients First." Harrington asked what it meant as was told "it means what it says." It's that simple, he noted. "It's like saying grace before dinner."

The session closed with questions and answers, in which an attendee essentially asked how to make the change. Harrington's answer: "Start." He then added, "Go home, identify the problem, and start a PDSA. What paralyzes this process of change is not starting."