The Triple Aim will never be realized without increasing our ability to engage patients in their own care, and nothing is more critical to patient engagement than the access patients have to their care providers. I recently attended the fourth Annual Thought Leadership on Access Symposium (ATLAS) which was held in Boston and sponsored by Kyruus. The entire program underlined the core relationships between access, patient engagement and the Triple Aim.

I have had the pleasure of serving on the clinical advisory board of Kyruus since 2014 and have attended all four of the ATLAS conferences. Kyruus is a Boston based company that was founded with the idea that the referral process in large systems could be improved if there was a tool that matched patients to the right provider. One of the co-founders and its CEO, Graham Gardner, is a Brown Medical School/ Harvard Business School graduate who is a former Beth Israel Deaconess Chief Medical Resident and BIDMC trained cardiologist. The CMO, Erin Jospe, MD, has practiced for many years as a PCP in IM at the BIDMC and Atrius Health. Both of them are committed to the idea of putting the patient first in the pursuit of the Triple Aim.

Last week’s main topic was patient engagement. This posting is an attempt to enlarge on the concept of patient engagement as well as connect with other recent posts on innovation, competition, and systems integration. Kyruus is evolving a body of knowledge and a collection of products that support all of these potentially positive mechanisms for moving us closer to:

…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time, …in settings that support caregiver wellness…

Over the last four ATLAS conferences the participation has grown from a few dozen administrators and the rare physician from handful of academic medical centers in 2014 to more than 140 participants from over fifty systems from across the country for this fourth conference. The most remarkable change that I have observed as I have followed Kyruus, and gotten to better know some of the systems that are using its products, is how a straightforward idea about how to improve a single issue to the benefit of patients can have such a large impact on an organization and its providers.

The original product was designed to help improve the referral processes in dispersed systems that typically have a “hub and spoke” architecture where affiliated hospitals are spread over a large geographic region with each hospital in the system surrounded by primary care practices and specialists with offices either in the community or in the outlying regional hospitals. In such a far flung system timely referrals from primary care to the most appropriate specialist can be difficult.

Imagine the waste, both from the position of the patient and the physician, when a patient travels 25 miles in heavy traffic to see a doctor who is a specialist that does not have expertise in the particular subspecialty procedure that matches their concern. Imagine a patient’s delight when they are matched with a provider who is fluent in their language. The problem of matching patients with the most appropriate doctor for them may seem easy to solve but there are “many devils in the details.” The solutions, the learning, the insights and the possibilities that have evolved in less than four years are amazing.

No matter how the political issues in healthcare are resolved, patients will likely remain worried about access as well the cost and quality of their care. Hospital and health system administrators will still be facing concerns about the decline in revenue relative to their costs. Physicians will still be worried about their clinical autonomy and financial security. Nurses and advanced practice clinicians will be concerned about all of these things and how to be more effectively integrated into a system that takes them for granted and gives them less professional respect than they deserve. New tools like the ones that Kyruus is developing should be able to mitigate some of the uncertainty that lies ahead for all of us.

The balance between enthusiasm for a new and potentially innovative technology and trying to understand and improve the environment into which it will be introduced is a challenge. When I discussed the challenges facing anyone attempting to introduce an innovation a few weeks back, I focused on the disruption to the status quo that innovation created and the resistance that it engendered. I failed to point out that one strategy to overcome that resistance is a process of co creation between the innovator and the potential user of the innovation.

By co creation I mean an intense development process that is a “catch ball phenomena.” The idea and the solutions are tossed back and forth between the creators and the potential users. Atul Gawande has said that healthcare does not suffer from ignorance, but rather incompetence. We have fabulous technologies that were largely developed through skillful application of the scientific method. We have well trained physicians and other participating clinicians who are eager to apply their knowledge and those technologies to improve the health of individuals and the whole population, but we fail in the distribution and access to those technologies and that knowledge.

We have not effectively applied the principles of the scientific method to the implementation and creation of access to our technologies and the knowledge of our clinicians. We are not so good and frequently totally fail at getting the knowledge to the patient or the patient to the knowledge in a timely way that is as efficient as possible for both the patient and the clinician who might help. Kyruus is developing tools that will benefit us all as patients connected with the provider most appropriate to engage them in improving their health.

The ATLAS conference is part of the intense process of co creation that Kyruus is pursuing with its users.  When I first started listening to the conversation between Kyruus, its users, and the sources of expert knowledge and advice it was bringing to the ATLAS symposiums, the conversation was mostly about creating data bases that described the preferences and skills of physicians and making sure that the patient got to the right provider for an office visit. Now the conversation has exploded into discussions of increasing patient engagement, change management within systems, and effective utilization of e-health.

During one presentation entitled “Change Management in Regards to Engaging Patient Groups,” which was essentially a discussion of leading change with physicians, I wanted to hug the panel composed of Dr. Chi-Cheng Huang of Lahey, Dr. Marjorie Bessel of Banner Health in Arizona, and Dr. M. Alex Schiffiano of Summa Health in Ohio, as the discussion of managing change with physicians became an in depth discussion of the burnout of physicians and all other healthcare professionals. Dr. Erin Jospe effectively drew out all the issues from this knowledgeable and committed trio of physician leaders.

 

I knew I was listening to people who cared when Dr. Huang described his experiences in practice and surmised that the number coming from the Mayo studies that suggested that 50% of doctors had experienced burnout was low. Dr. Bessel thrilled me when she referenced the Quadruple Aim. Dr. Schiffiano was able to compare the realities of practicing at Kaiser, an organization that has been leading change since it was founded in 1945, and at Summa, an organization where physicians are on a new journey from practicing independently to practicing collaboratively. The “I to We” journey is preparatory to improving a system to effectively engage patients. A system must have the diversity of professionals organized in effective teams to create a supportive environment if clinicians are to be successful in engaging paints in the co management of their concerns. All this from the idea of making more effective referrals.

Understanding and managing the “bench strength,” practice diversity, and individual performance within a large medical system can be beneficial in ways far beyond patient convenience and engagement. We live in an age of increasing transparency and many of our clinicians are learning for the first time that data that reflects a view of them that they may not like is accumulating rapidly. Systems managers are quickly understanding that the future will continue to produce relatively lower reimbursements. To remain competitive cost and service issues can not be ignored.

For years since reading the book, Moneyball: The Art of Winning an Unfair Game (2003) by Michael Lewis, I have said that it was the best business book I have ever read. The A’s  were struggling with inadequate resources in a small market. Baseball was dominated by teams with the money to pay players much more than a “small market” team could afford. The book, and the movie that followed, tell how a baseball veteran, General Manager Billy Beane, combined efforts  with a young “nerdy” data guy from Harvard, Paul DePodesta, who could turn data into insight and then insight into the appreciation of value to achieve success against better financed teams.

One concept they used was that they could win without superstars who had many talents if they could build a team of people who were good at one thing. That matches with “team based care.” Another concept I liked was the realization that in a nine inning game each team had only 27 outs. That insight leads to the realization that wasting outs is bad. The correlation to ambulatory practice is that the average doc struggles to deliver 27 appointments in a day. Wasting appointments because of a poor match between the doctor and patient is bad. Wasting anything is bad. Finally, getting on base is necessary to score runs. The winner is the team with the most runs and not necessarily the most homeruns. Getting on base anyway you can is good. Players who consistently get on base are valuable and can help you win even they are not impressive power hitters.  That correlates with doing the little things well.

DePodesta, who is now working for the Cleveland Browns as their Chief Strategy Officer was the last speaker before Graham Gardner, the CEO of Kyruus, gave the closing remarks that summed up the experience. He was an excellent speaker who touched on the philosophy of Thomas Paine and reviewed the biases of analysis as described by Kahneman and Tversky. (It’s interesting that Michael Lewis’ latest book is about their incredible partnership that launched Behavioral Economics.) DePodesta informed us at the end of his talk that he was moving his interest in data analysis into healthcare. After reading Eric Topol’s book, The Patient Will See You Now, he called up Topol and is now working with him at the Scripps Institute. Healthcare leaders who think about what creates value have a lot to learn from the story of the A’s and the insights of Beane and DePodesta.

It is amazing to see where a little idea can take you. In these difficult and frustrating days the ability to look above the weeds and find the strength to improve will be a necessary competency. The other inspirational speaker at ATLAS was a former Navy SEAL, Brent Gleeson, who used his personal experiences as a SEAL and the motto of the SEALS, “The only easy day was yesterday” to inspire those listening to remember that the work we do draws its meaning from the patients we serve. There should be satisfaction and personal reward despite the difficulties and the challenges of meaningful work that needs to be done. Our goal is a better system of care that understands that patients deserve and need access to care in a system where clinicians are supported to engage them in a journey toward better sustained health, or as I love to say:

…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,…in settings that support caregiver wellness…

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