The Secret Sauce of Office Practice Redesign

This issue marks the third year for devoting an issue to health information technology (HIT). Computer applications have already changed front office procedures, and their clinical applications are spreading to change the face of medical practice. The computer with an EHR is becoming the “third person” in the exam room. Increasingly, that computer contains not just the patient’s health record but rapid access to all medical knowledge.

2009 may go down in history as the year of healthcare reform in America. If not, it certainly will be the start of major change. The current wasteful and inefficient non-systems of care are not sustainable. We need methods that are better, faster, and cheaper — the dream of any redesign engineer.

The imperative of healthcare redesign for today is to achieve a combination of cost reduction, quality improvement, and service improvement. All that is possible today with HIT applications and new methods of care. Major change has happened in most other service industries and will happen to us in medical office practice. Secure online communication with patients, even automatic communications for things like making appointments and refilling some prescriptions, is just one of the many efficiencies that HIT will bring to office practice to improve service and lower costs.

Besides using Internet communications, how do we improve the quality of outcomes and improve service while lowering the cost of care? Current office practice is reactive, episodic, and physician dependent. Our workday has us reacting to whatever is on our schedule and whatever urgencies arise. Our care is delivered episodically during office visits. As physicians, we carry the major responsibility of providing the totality of medical care to our patients. We are in charge of ensuring that our patients get all the preventive services, chronic illness care, and acute care they need. As medical knowledge grows, this responsibility becomes overwhelming. New methods of care are needed.

Despite our best efforts, traditional office practice results in only about 25 percent of our patients getting all their recommended services or having their outcomes of chronic illness care at the target levels. It is easy for us to say that the responsibility for these gaps is on the patient. If they just came in regularly and complied with all our care, many more would be at target. While this is true, there are emerging models of care that are achieving much better outcomes.

Demonstration projects of chronic illness care have shown that working differently may result in improved quality of care at lower cost. There is a “secret sauce” of care strategies that when put together have a major impact on the outcomes of care to a population of patients. The three “ingredients” to this secret sauce are: making the process of care continuous rather than episodic; being proactive with care rather than reactive; and activating patients for greater self-management. While these three strategies can be done without HIT, using HIT makes them much more efficient and begins to move healthcare into modern processes much like other service industries today (banking, travel, accounting, etc.).

An online platform of communication and care services makes the access to care continuous for patients. They may log into their personal medical home anytime and have access to their medical record and participate in whatever care services that are available. The online platform allows both sides of the care equation — the physician team and the patient — to communicate around care at any time asynchronously at mutual convenience.

Once a practice has a registry of all its patients and is able to stratify patients by age, sex, preventive services, and any given disease, proactive strategies of care may follow. If you want to know how your diabetics are doing, turn on the computer application and look. Rather than spending the day reacting to the patients that are on your schedule, you and your care team may embark on productive interactions with patients to improve their care. With better information systems, care to a population of patients may become strategic. Of course the finances must support this proactive care and reward better outcomes. That is where pay-for-performance, or, better stated, payment for results, replaces payment for just doing care.

Once patients get their medical records and are linked into us as their providers of care, why not let them take a greater role in their own care? We know what preventive services we want our patients to have; why not let them obtain them directly? The experience over the past decade of studying patient self-management shows that the more the patients are involved in their own care, the better the outcomes. Conversely, the more the patients remain totally dependent on the physician to provide all the care, the worse the outcomes.

The tools of HIT do not improve healthcare without the right applications. HIT is not the answer. People using HIT wisely have the potential to redesign care for the better. HIT creates new processes of care that offer the potential to greatly improve the outcomes of care. The financing of care is moving toward improved outcomes to a population of care. All physicians may begin to apply the “secret sauce” concepts to improve quality and service at lower costs. What an exciting time to be in medical practice.