I believe that we must become more effective practitioners of patient patient engagement if we are ever going to have any hope of achieving the Triple Aim. Dr. Ebert told us what would not work in that quest. He said that more money, more personnel, and more facilities were not the answer to the question of what “will provide optimally for the health needs of the population.” His answer was that the job of improving the health of the nation would require the organization of the personnel, facilities and financing into a [more effective] conceptual framework and operating system.

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”

The statement is beautiful and directionally correct at a high level. It states a hypothesis that I have treated like a law of nature. My esteem for its wisdom is manifested by the fact that I have quoted it hundreds of times. Dr. Ebert’s statement is cryptic and purposefully avoids specificity. It is a high level ambiguous answer that does not ever describe the optimal operating system and finance mechanisms that will do the job. I resolved that concern for myself by realizing that there are several management systems and finance mechanisms  that answer the riddle. I have come to believe that as long as the operating system and finance mechanisms support the establishment of delivery systems that meet the criteria published in Crossing the Quality Chasm progress will be made.

1)    Care based on continuous healing relationships:

2)    Customization based on patient’s needs and values.

3)    The patient as the source of control. Encourage shared decision-making.

4)    Shared knowledge and the free flow of information:

5)    Evidence based decision making.

6)    Safety as a system property.

7)    The need for transparency.

8)    Anticipation of need.

9)    Continuous decrease in waste.

10)  Cooperation among clinicians. [“I to we” within practices, across practices, across systems and throughout the community.]

I have come to believe that management by process as facilitated by Lean, and value based payments that are built on budgets that support the principles of caring for a population get my nod as a step closer to the specificity necessary to achieve the Triple Aim which is a little more specific than provide optimally for the health needs of the population.

As I think about the list that was generated by Crossing the Quality Chasm in 2001, I would make one addition that I believe may bring us closer still to the Triple Aim. The operating system and finance mechanisms should support patient engagement. I know that some will push back and say that it is there in a combination of # 1-5 plus 7 and really is echoed in every descriptor on the list, but I think it should be a list of 11. The goal of the operating system should be an evolution that optimizes patient engagement.

I know that finance is a huge barrier to patient engagement. If a patient does not have access to care it definitely impedes engagement. If the finance system is so laden with copays and deductibles that it makes patients reluctant to access care, then we have a problem. Maybe Bernie and Elizabeth are right, single payer could reduce the cost of care. I am sure it would facilitate patient engagement.

Lean contributes to patient engagement through its philosophy of the primacy of the customer and the importance of its emphasis that systems should be managed to produce value for the customer. Ironically, even in a very commercial environment, creating value for the customer is the most reliable way to “increase shareholder value.” Lean supports providers in their primary objective of serving patients and better functioning systems derived through the wisdom of the people who provide the services that support care including patient engagement.

What amazes me is that our systems have been so focused on volume objectives that they are a barrier to the objectives that managers are trying to achieve and the relationships providers intuitively know are required to achieve those objectives. Ordering a $2500 MRI as a substitute for a fifteen minute conversation will rarely promote the objectives of the Triple Aim, and when it comes back as negative we may close the question but the patient is still concerned if the precipitating problem persists.

There are many ethical reasons to support efforts to improve patient engagement, but there are some practical considerations to mention to help motivate us to change in ways that improve our ability to effectively engage patients in their own care. An effective way to lower the total cost of care for a population would be to manage chronic diseases like diabetes, COPD, CHF, asthma, and chronic early renal failure so effectively that an admission to the hospital for any of these diagnoses would become a “never event.” That audacious goal can only be approached by much more effective patient engagement that enables either improved self management or augments outreach efforts like home visits and telemetry. Self management may not be possible for some severely compromised patients, but effective engagement of family or designated caregivers can be effective facsimiles.

I believe that systems should be engineered to support patient engagement. The first step is to engineer patient flow in ways that promote team based care and a redistribution of work that is designed to give clinicians the time necessary to promote the self management which is a primary goal of patient engagement. My friend and colleague at Simpler, Dr. Paul DeChant is probably the most articulate proponent for efforts to improve care delivery in ways that reduce clinician burnout. Burned out clinicians whose enthusiasm for patient care has been replaced by depression and a self protective wall of cynicism can not promote patient engagement and often refuse to engage when a patient clearly has a desire to know more to enable self care. Paul’s goal is to “return joy to patient care.” Paul has taught me that we will never achieve the Triple Aim unless we make it a Quadruple Aim and modify the IHI statement that we want

…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,

…to include

…in settings that support caregiver wellness…

Fixing what causes over 50% of physicians to suffer from symptoms of burnout to the point of resenting what they are required to do to deliver care in a dysfunctional system ( over 40% of behavioral health docs on the low end and 59% of intensivists on the high end) is a good place to start in our effort to more effectively engage patients.

I chose healthcare as a profession because I wanted to help people be healthy and enjoy their lives. I was very fortunate to have had the opportunity to realize that objective in an organization that was created to prove Dr. Ebert’s theory. We had team based care before you could find those words in the literature. In practice we were a medical home from moments after the concept was first described in the pediatric literature in 1967. We had an automated medical record on day one of existence in October 1969. We always were financed based on the principles of value based reimbursement and the necessity to budget for the expense of delivering care to a population. We were early adopters of the principles of quality management and improvement science. In short, I was lucky to spend my years in practice in an environment where I could respond to the innate desire of my patients to be a participant in their own care working with colleagues who shared the same goals.

Our desire to practice in a new and unique way that embraced the importance of fostering  patient education with the goals of engagement and self management did not protect us from the pressures of a competitive market, or the challenges coexisting with business partners who had different values, but the ideals did sustain us and create a resilience that was an effective counterbalance to our challenges. In our most difficult moments the vision of what was best remained as a motivation to find a way to overcome the challenges. Patients who had become engaged and appreciated the partnerships that they had established with us remained loyal to the mission as well and sustained us when we were struggling.

The interactions that promote patient engagement and partnerships between clinicians and patients are a great example of a “non zero” interaction that foster progress. Non zero relationships or “win-win” transactions were well described as essential to improvement by Robert Wright in his book Non Zero. The transactions between patients and their caregivers that foster patient participation and engagement “create capital” and are essential to the hope of ever achieving the Triple or Quadruple Aim. Dr. Ebert’s hypothesis calls for a “non zero” solution.

Perfection is not necessary in the clinician/patient effort to establish a collaboration that supports individual health and enterprise success. More often than not there will be problems and failures that can be captured and become the sources of insights that move the patient toward a more stable condition as the “failure” provides the insight for system improvement. Failure informs both the patient and the clinician and should inform the work of the system if there is an effective deployment of Lean principles.

As I look back on my practice years, what I remember most fondly are my collaborations with my engaged patients. I gave them information and they gave me information. I often learned that the care plan we developed was wrong, or that it was theoretically correct but practically implausible. They had an expertise that I could transfer to other patients. That is an example of a non zero interaction. At the end of my career I had the chance to practice in a shared medical appointment environment. It was an incredible exercise in patient engagement. Patient engagement is a learning process. Patients learning from other patients and the doctor at the same time is an enhanced learning process. I have had equally satisfying experiences of care facilitated through the electronic patient portal and I wish that I practiced long enough to enjoy the potential benefits to patient engagement that might be realized with new tools like “Watson.” The overriding point is that different people respond to different approaches to engagement. Our challenge is to continue to explore ways to bring more and more of our patients into an active role in their own care.  

The search for innovations that optimize patient engagement will be facilitated by management systems and finance mechanisms that can adapt to exploring new ways of optimizing patient engagement which was possible but always difficult for both the clinician and the patient in the standard fifteen minute medical appointment. There is so much to learn. There are so many potential solutions. I wish I could start all over knowing what I now know. That is not going to happen for me, but I hope that you will be an advocate for yourself as a clinician or as a patient. Everything we try, as we attempt to find the answers that will provide optimally for the health needs of the population should be passed through the consideration of its impact on our efforts to enhance patient engagement.