Dr. Brian Stork introduces MUSIC, the Michigan Urology Surgical Improvement Collaborative.
Several years ago, after becoming board certified in urology, I applied to become a Fellow with the American College of Surgeons. I prepared a list of my surgical cases and complications and arrived for the required interview and interrogation. Being somewhat appropriately nervous during the interview, I can’t recall many of the questions that I was asked. The message that I took away from that experience, however, was very clear. A commitment to continuous surgical improvement was an expected part of membership in the college.
As I began my career, I first kept notes of my surgical successes and complications on paper. Over time, I moved to a spreadsheet. Not only was the process time consuming, it was difficult to directly compare my surgical experience with that of others. Differences in reporting were readily apparent even in the academic literature. There really didn’t seem to be any universally accepted standard for reporting in Urology. As a result, it was difficult to know exactly where to try to focus my continuous improvement efforts.
A couple of years ago, a solution started to emerge. The University of Michigan, under the leadership of Dr. David Miller and Dr. James Montie, initiated a statewide collaborative between academic and private practice urologists. This collaborative, financially and administratively supported by the Value Partnerships Program at Blue Cross Blue Shield of Michigan, became known as the Michigan Urological Surgical Improvement Collaborative (MUSIC).
A diverse group of practices from all over the state started participating.
Each participating group chose a physician leader and employed a designated data abstractor. Outcome measurements were defined by physicians and entered into a standard database by the abstractors.
Physician leaders and abstractors from around the state then started regularly meeting to look for trends, and to try to identify opportunities for patient care improvement. As the data started to mature, it started to become possible to have real discussions around the best standard of practice, both at the statewide level, and at the individual practice level.
In our own practice, some of these discussions have been intense. Not everyone agrees on the best way to interpret the data. In my experience, however, these discussions have always been respectful and productive.
These days, quality improvement initiatives are seemingly everywhere. Many of these initiatives are in reality a distraction, taking physician time away from direct patient care. Physician leadership and feedback are often lacking in such activities, thereby limiting the potential to facilitate meaningful change.
MUSIC has turned out to be more than just an exercise in agreeing upon metrics and collecting data. It has been an opportunity for academic and private practice urologists to ask the questions and learn from each other in an effort to continuously improve urological care.
Working together “in concert” also includes patients.
Soliciting and involving the patients fully in decisions, and helping them make better decisions, is something we are all interested in, and working towards quite expeditiously. – Dr. David Miller
The interview starts out with general information about the program but relatively quickly begins to demonstrate the interactions and collegiality made possible by the program. As a private practice urologist in a relatively small community, I am excited and proud to be involved in the MUSIC initiative. I truly appreciate the relationships and improvements in patient care that have become possible as a consequence of this effort.
To think about why this works is there’s some secret sauce to the combination of the relationships, the data, the fact that we are competitive, and we all want to get better … What the collaborative does is it provides us with a “community of coaches” to think about how we provide care, to offer constructive feedback that we can take and improve upon, and then close the loop, to see if we are actually getting better.” – Dr. David Miller
Lewis M. Levy, MD
Vice President Corporate Medical Quality
Best Doctors, Inc.
Dr. Joseph Antin, a hematologist/oncologist at the Dana Farber
Cancer Institute in Boston, has been a Best Doctor since 1996. He was popular choice among our medical directors for November’s Expert of the Month. He has written many Best Doctors Expert Reports for our members over the years.
“I just like to get the job done,” said Dr. Antin, when asked about his commitment to participating in our case consultations. It’s a simple answer that amplifies the character of such a great physician Dr. Antin enjoys the challenge of difficult cases and the opportunity to help physicians around the globe get to the right diagnosis and treatment path. Trisha Penta, RN, a member of our nursing staff at Best Doctors, was a strong supporter of Dr. Antin’s nomination as our EOM for November. She noted, “When looking for an Expert to take on a challenging case in I can always count on Dr. Antin to show interest in participating. I cannot think of a more deserving Expert to be recognized as an EOM and that is why I voted for him”.
For Dr. Antin, educating patients on their disease is a motivator in performing case consultations for Best Doctors. He states, “Patients who are educated about their disease do better coping with their disease.” By blending his interests in investigation, clinical research, basic science, patient care, he hopes to help patients better understand their disease on a more in-depth level.
Promoting engagement among patients in their healthcare is at the heart of our mission at Best Doctors. By promoting proper education and patient engagement, we believe patients can partner with their physicians to take control of their own health. Physicians like Dr. Antin are furthering healthcare by fostering an environment of collaboration, we are honored to work alongside him in these efforts.
If you are an elected Best Doctors Expert and are interested in learning more about participation in our Expert Review Program, please email us at firstname.lastname@example.org.
Back in 2008, I opened a personal Facebook account. Not for myself but so I could stay ahead of my children in the world of technology. Fast forward five years and I am the social media manager for a three-doctor LASIK practice in Charlotte, NC and manage six social media accounts.
Running a social media campaign in a medical practice can be an intimidating prospect, but here are five easy ways to nurture and grow your practice with social media.
Len Fromer, MD
Executive Medical Director, Group Practice Forum
Assistant Clinical Professor
Depart. of Family Medicine, University of California at Los Angeles
When you build a patient-centered medical home (PCMH) on principles like advanced access to care, care coordination, and managing transitions of care, you must address how current processes need to change to meet your patients’ needs and wants.
Every patient needs — and expects — the right diagnosis and treatment. One of the first places you can look to implement process change in your PCMH is by establishing new standards for screenings, tests and other preventative care measures.
Start by reviewing your current standard operating procedures for each disease and the screenings and tests you would traditionally recommend for a patient. Then ask yourself a simple question: Is this test necessary? Will it yield information that will change the diagnosis or treatment path? For example, if you notice that most of your low back pain patients end up in physical therapy, regardless of whether they received neurology consultations or an MRI, perhaps you should consider establishing physical therapy as the first treatment, rather than as a third or fourth option.
If you’re still not sure about eliminating a test, visit a website like ChoosingWisely.org for recommendations on which tests and screenings may be wise to avoid.
In addition, be sure to document process changes so you can track patient outcomes and report the data to payers when necessary.
What patients want from health care is a different story. Patients need the right diagnosis and treatment; they want more access to you and your care team. In simplest terms, access to care is what many patients associate with receiving better health care. You can make a difference in this process area by assembling a talented, dedicated staff and providing them with the tools they need to deliver on the team-based collaboration principles of a medical home.
The transformation to a PCMH requires many process changes to your practice. These changes will not happen overnight. So as you continue to build the framework for your PCMH and implement process change, evidence-based medicine will help you move from volume-based care to value-based care. Keep in mind that you can’t discard all volume-based care model efficiencies that are successful in your practice. In fact, during the early stages of your transformation you will find your PCMH with one foot in a volume-based care model and the other in a value-based care model. Still, it’s important for you to keep driving the change to transform the medical home into a place where you consistently deliver value to your patients: great outcomes, great care experience, at a reasonable cost.
Kurt Elward, MD, MPH
Family and Internal Medicine
Director for Quality Initiatives, Medical Society of Virginia Foundation
One of the most crucial factors in successfully implementing the patient-centered medical home (PCMH) model is involving every member of your care team in the transformation.
Here are a few tips on how you can engage your staff in the PCMH:
A PCMH kick-off meeting is a great way to communicate your vision, get feedback, and listen to the thoughts and concerns of your staff. It’s also an opportunity to identify the ways that your practice has been meeting medical home criteria and which processes need modification.
In many healthcare systems, top-down change is the standard model. But in a PCMH, there’s a real opportunity to take into consideration every voice on your care team. This kind of bottom-up change is very powerful in not only establishing a new approach in the practice, but also in helping the staff feel more in control of the changes that you’re making to the practice.
Identify the strengths of your staff and find ways to incorporate new PCMH roles into existing roles. Is there someone in your office who is meticulous and loves gathering data? This person could be tasked with registering patient data into an electronic health record so the entire staff has access to the information. As an added benefit, now your medical assistant can concentrate on what he or she does best, like clinical evaluations or health maintenance screenings, instead of data entry.
Great leaders have people around them who share their goals and aspirations. Select a “PCMH champion” from your staff (or several, if in a large practice) to help communicate goals and assignments.
Your positive energy and attitude is critical in setting an example for the medical home. You’ll find that when you and other doctors display a positive attitude throughout the day, the staff will respond to your energy. Your staff will follow your example. But you and other doctors need to be active partners and participants in the transition to a PCMH.
The journey to PCMH status requires a fundamental shift from physician-based care to team-centered care. Staff roles and workflows will change. A new culture will emerge. It’s important to engage your entire team throughout the process to make them feel invested in the changes. By doing so you’ll not only build a better PCMH, you’ll also build a better team.
Kurt Elward, MD, MPH
Family and Internal Medicine
Director for Quality Initiatives, Medical Society for Virginia Foundation
One of the challenges in implementing a patient-centered medical home (PCMH) is envisioning how the new style of practice will function and grow over time. That’s why it’s important to develop (yes, that means write it out) a leadership plan that will help ensure a smooth transition from your current practice model to PCMH model.
Here are 4 key elements that are critical to have in your PCMH leadership plan:
1. What are your overall PCMH goals?
What is your vision of your practice as a medical home? How does it sync with the care you have always tried to provide? What strengths does your practice already have that can serve as foundational cornerstones for your PCMH? Determine the specific goals that you have for your practice. Include a timeframe for each goal so everyone on your team is focused on moving the change process forward. I would advise small steps on a clear but flexible trajectory, to allow early wins and to help give you a sense of the way your team is transitioning.
2. Decide responsibilities
Describe how each person in the PCMH will contribute to reaching your goals. Better yet, get together and ask them what they feel their role is in a PCMH. You may well be surprised and pleased. At the same time, try to identify natural or potential leaders for specific elements of the PCMH. What are Gloria’s interests and skills? How does Matt fit for specific projects? In the chain of events for a patient visit, who will be doing what, at which times?
3. Identify decision makers and resources
Choose who will be in charge of certain decisions at the PCMH. For example, you may want to have a member of your staff accountable for patient registry, while another team member coordinates plan visits. Also, it’s beneficial to determine the resources that you rely on inside and outside your PCMH. Spread the authority around to some extent, but expect project reports and have a clear reporting/responsibility process. Some of your best ideas and strongest work may come from your medical assistants, front office and checkout staff. A sports team does not succeed with all one type of player. In baseball for example, there are nine jobs that have to be done well – there are multiple jobs that can be done well and yet interface with the practice team to move your goals ahead!
4. Create a Budget
Will you need to hire more people? What other resources will you need to support the change team? Be sure to forecast the costs associated with meeting the growing demands of your medical home. Areas of cost include:
Training staff in disease state review, customer service, team leadership
Many doctors have already created successful PCMH leadership plans. Reach out to these colleagues. Take advantage of their expertise and find out what has worked for them. Surely you have your own strategic vision of what you want the PCMH to be. However, by incorporating some best practices into your leadership plan you’ll provide a solid foundation for the future of your PCMH.
One last note: Before you write your leadership plan make sure to get ideas and input from your practice partners and key members of your team. You can even designate “PCMH champions” and delegate parts of the leadership plan to these team members. In fact, bringing a few “PCMH champions” on board has many benefits. You’ll not only receive practical recommendations from staff members who are well-qualified to address specific elements of the plan, but your team will feel more engaged and a greater part of the overall process. Plus, if a few members of your staff write part of the leadership plan, it’s an easy way for you to make sure the team understands your PCMH goals.
This originally appeared in Dr. Luks personal blog on October 8, 2013
Are You a Digital or Social Physician, or Both?
I see many people using the terms social and digital interchangeably. Some doctors are digitally savvy. But that does not mean that they are also socially savvy, or that they have the skills to make the most of today’s digital social tools. I thought this might be a good opportunity to open up this discussion.
One is online sourcing for lifelong learning, and inbound utilization for content needs. Another is using digital tools to improve upon office workflow efficiency.
Perhaps the most useful value proposition for healthcare overall is to utilize technology to facilitate education and communication with our patients and colleagues to improve upon the overall healthcare experience.
Using social media to advance industry knowledge or to grow a professional network is very important, but there is so much we can learn from patients, patient support groups, and people who are just seeking health information. Physicians can help patients find each other, too.
There is also much more patients can learn from us, their trusted advisors. Being a social doctor means you are interested in collaborating, sharing information, and lending your expertise.
These are the challenges for the 21st century physician, being digital AND social.
A digital and social doctor uses digital tools for effective social communications with peers, and with patients!
Robert Chessin, MD
Pediatric Healthcare Associates
Today, insurers use a different set of parameters to determine payments to patient-centered medical homes than the traditional reimbursement systems.
Let’s take a look at several factors that could have an effect on your reimbursements.
When it comes to preventative medicine, the number of well visits or checkups is one of the key factors in determining reimbursement. Another factor is the frequency of immunizations, not only for children but also for adults with certain disease states. And finally, payers will look at your screening tests. Many screening tests that were at one time thought to be unnecessary are now recommended. For instance, it’s now suggested that children ages 10-12 undergo regular lipid screening to detect genetically based or physiological signs of hyperlipidemia.
Payers want to see that your patient-centered medical home is operating effectively and efficiently. That’s why they want to be sure that your practice is performing helpful screening tests while avoiding unnecessary tests and medications for acute care.
For example, let’s say you diagnose a patient with pharyngitis. The payer will want to check that you performed a throat culture as well as make sure that antibiotics were not prescribed unless the patient had a bacterial inflection like strep. Or, if a patient has an upper respiratory infection, the payer will check to see that antibiotics were not prescribed. Most upper respiratory infections should not require antibiotics.
For chronic care, payers will verify that your practice is following evidence-based guidelines.
At my patient-centered medical home in Connecticut, we’ve set up a system to see how often asthma patients refill their prescriptions and make follow-up appointments. Our asthma disease registry also helps us proactively monitor the progress of patients.
In addition, your chronic care management and care coordination must be of the highest quality. Payers need to be assured that you are providing the necessary care to help patients understand their condition and improve their quality of life. Your coordination of care with people outside of your practice also plays a significant role. Payers will want to see how closely you work with specialists and visiting nurse programs, among others to provide your patients with the highest quality of coordinated care.
Another major factor in determining payment is the cost associated with care. Payers will frequently look at how often you are writing generic prescriptions compared to branded equivalents. They will also review your emergency room patient visits and hospital admission rates for ambulatory based diseases to see if some visits can be prevented.
Of course, patient satisfaction is of paramount concern to everyone at a patient-centered medical home. And payers are quite interested in the overall patient experience as well. Payers expect that your patients have easy access to care and feel comfortable interacting with office staff.
What can you do? Here are 3 easy ways to increase patient satisfaction at your medical home:
The shift in reimbursement methodology from quantity of services to quality of patient outcomes is still evolving. But with a value-based system, payers are finding that patient-centered medical homes can reduce health care costs while improving care and empowering patients.
Lewis M. Levy, MD
Vice President Corporate Medical Quality
Best Doctors, Inc.
Starting this month, Best Doctors will recognize one of our elected Best Doctors experts as Expert of the Month. Voted on by our amazing nursing staff and group of medical directors, who have a detailed understanding of what it takes to be a Best Doctor, we seek to honor the Experts who have made a lasting impact for patients seeking the right diagnosis or treatment through our services.
Our inaugural honoree is Dr. Edward Craig, an orthopedic surgeon who resides in Connecticut and practices at the Hospital for Special Surgery. Dr. Craig has been a Best Doctor since 1996, and has written 96 case consultations for Best Doctors.
“What’s interesting to me is to problem solve, to clarify information, to put confusing information into perspective,” Dr. Craig said. “One thing I’ve enjoyed about working with Best Doctors is that the background and legwork are done for you and done well. The clinical summaries are very digestible, and you can get through the essence of the problem expeditiously. It makes writing consultations enjoyable and efficient.”
His long history of providing expert consultations for patients through Best Doctors is reason enough to vote Dr. Craig our first Expert of the Month, but as Dr. Erin Jospe, Medical Director of Global Physician Services, said, “Dr. Craig exemplifies the type of physician we strive to have on our list. He believes in patient safety and strives to provide the best opinion he can for each and every patient.”
Patient safety is a theme he cites as he explains his approach to Best Doctors case consultations, and to the practice of medicine.
“It’s difficult sometimes for patients to make an informed decision about their healthcare. I think patients walk into an office with a certain amount of trust, which is difficult, because you walk in there, to a perfect stranger, and lay yourself out, physically and emotionally,” said Dr. Craig. “For those of us studying medicine, you take that trust as something sacred. That’s always the challenge, and I look at my work with Best Doctors as if it’s my own patient.”
With skill, knowledge and altruistic intent, Dr. Craig has become not only a life-changing force for the patients on whose cases he’s consulted, but a fantastic example of the Best Doctors Expert.
“I think a Best Doctor has to start out with the knowledge and experience to be able to sift thought information and give a reliable, trustworthy opinion, and someone who has credibility in the eyes of their peers,” said Dr. Craig. “But there are a lot of smart doctors around. I think this experience is for those who are interested in taking the time to frame information into the language of the patient. Someone who is not afraid to echo an opinion that’s already been given, who doesn’t need to be smarter than everyone else, but who is also not afraid to disagree.
“The other Best Doctors I know are that kind of person, and I’m honored to have been counted among them.”
In Medicine, the attending-fellow-resident-medical student hierarchy is valuable to a certain point. When we treat the person below us with disrespect, this attitude becomes ingrained into our culture. How can we expect our residents to have respect for patients when we don’t have respect for our trainees?
Would you go to a financial advisor who was about to file for bankruptcy? Would you consult a tax attorney who was getting audited for the umpteenth time? Would you trust a veterinarian who hated animals?
I’m sorry and disappointed to say this. Doctors are sick and it begins with our training.
A Culture of Broken Communication
It was my senior year in residency and I was in charge of running the department. I mentored residents, managed the flow of the department, and was supposed to be a liaison between nurses and MDs.
At least that was my job description.
One intern was starting his shift, Brian*. An attending was ending his shift, Dr. Lee*, a brilliant well-known physician who was notorious for “pimping” his students. He was even known for a quote that he had taped on the wall, “Pimp your students to places that have never been pimped before.”
Brian asked, “Hi Dr. Lee, can I present a few patients to you?”
Dr. Lee responded, “No, my shift is about to end and I am going to call it a day.”
Brian smiled and said, “Aww, you son of a B.”
That is when everything took a quick turn for the worst. Dr. Lee feeling disrespected wanted to prove his seniority over Brian and make an example out of him. Following an awkward interaction, Brian was on his hands and knees doing pushups.
Dr. Lee had won; he had broken Brian down and shown everyone who the leader of the pack that night was. I still have dreams about that night. If I had said something would it have played out the way it did? If I could relive the situation, I would have said at the first sign of conflict, “Dr. Lee. Brian. This is not the place or time to have this discussion. Let’s go to the MD lounge right now.” I would have gripped them both by their arms and then lead them out.
Time to Make a Change
The saddest part of this is that nearly every doctor and medical student has a story like this or has heard of a story like this. Unfortunately, that’s one too many.
Yes, doctors are artist-scientists trying to fight disease, but we are not soldiers trying to kill enemies. We are young human souls trying to make a difference. That’s why we came to medical school, studied until the late night, took all those tests, and the toughest classes.
Don’t kill our trainees’ spirits because you are burned out. Don’t kill our trainees’ spirits because you had to work harder than us during your training.
Help them thrive. Please.
What if we could give a training experience that you wish you would have had?
What if we encouraged our residents? What if we teach them to have a balanced, healthy life?
Ultimately, being a doctor boils down to the patients. I believe that by encouraging doctors to have a balanced, healthy life, they can in turn light a fire within patients, even society, to do the same.
*Names are changed