Editor’s note: The following post is a collaboration by Dr. Samantha Collier, St. Luke’s chief quality officer, and Dr. David Pate, president and CEO of St. Luke’s Health System.
Could health care have done better by Whitney Houston? As physicians, quality improvement advocates, and admirers of talent in the concert setting every bit as much as in the clinical setting, we’ve been mulling that question since the singer’s death Feb. 11.
We think some of the accountable care approaches we are adopting at St. Luke’s are the types of measures that in the future might help avert such tragedies.
I have written on accountable care in previous posts, but for those of you who are new to my blog, accountable care is the strategy that St. Luke’s Health System is pursuing.
Simply put, accountable care is better health, better care, and lower costs. Key features of the accountable care system St. Luke’s is rolling out are:
Just what does all this have to do with the untimely deaths of Houston and some other celebrities?
Test results are pending to determine the cause of death of Whitney Houston. But we know that Amy Winehouse, age 27, died of acute alcohol poisoning. And Michael Jackson, age 50, died from an overdose of propofol, a drug prescribed and administered by one of his physicians. Jackson reportedly had trouble sleeping.
Fame and wealth do not guarantee the best or most effective medical care.
Common Electronic Medical Record
St. Luke’s is implementing a common electronic medical record at a cost exceeding $100 million, in an effort to ensure that every caregiver involved in the care of a St. Luke’s patient will have access to all of the patient’s medical and medication records.
Those participating in the care of the patient will be aware of what other physician and non-physician providers’ assessments and treatment plans are (better care coordination). Tests will not unnecessarily be duplicated (cost savings). And prescribers, who otherwise might be unaware of a medication that the patient has received from another physician, can avoid prescribing a medication that might interact with other medication and cause harm.
It appears from published reports that Whitney Houston had prescriptions from more than one physician and from more than one pharmacy. Investigators have issued subpoenas to obtain all of the medical and pharmacy records.
A common electronic medical record can help identify such individuals sooner and alert caregivers to the need to address this abuse. Given that the Centers for Disease Control reports a death every 19 minutes in the United States due to unintentional overdose, it seems only logical that a common electronic medical record can save lives. And for every unintentional overdose related to painkillers, there are 35 emergency room visits related to the prescription drug use, and nine others admitted for substance abuse treatment. The opportunity for improved care is huge.
Clinical Integration and Evidence-based Medicine
One foundation of accountable care is the common electronic medical record. Another is a network of physicians who work together to identify and incorporate best practices and evidence-based medicine into their work-flows and who hold each other accountable for following these protocols and order sets to ensure that the best possible outcomes are achieved at the lowest cost for patients.
It is this opportunity, to get physicians working together in a coordinated manner to drive quality, that offers so much potential to decrease the fragmentation in health care services, improve the coordination of care, improve quality outcomes, and provide better value to patients.
In Michael Jackson’s case, how much better and safer might his sleep difficulties have been managed if the right specialists and experts had been involved in his care, utilizing evidence-based medical practices instead of the medication choice of propofol, a dangerous drug that no current evidence supports as being safe for use in treating insomnia at home, even with supervision?
Patient- and Caregiver-Centeredness
We must change the model of care. As it stands, care revolves around the providers of care. We need to have systems and processes in place that center around the patient and their caregivers’ unique preferences and goals.
I have spoken and written before about what some of these changes would involve – the ability for patients to schedule appointments online, email physicians with non-emergent issues and questions, access their medical records online, collaborate with their physicians and caregivers on personalized care plans that incorporate their goals and wishes, receive effective education and reminders delivered through technology, and a host of other components that meet the needs of a very diverse patient population.
In the past, we have tried to address the needs of the patient, sometimes to the exclusion of caregivers who support that patient. Caregivers have valuable perspectives and information that may help inform our treatment decisions.
While the world has been shocked by the untimely deaths of Houston and other superstars, there have been people near them who saw the signs of problems. When we include family, caregivers, and others who are important in the support structure of our patients under accountable care, we may learn of problems that a patient has not disclosed.
Further, when we coordinate care among the various treating physician and non-physician providers, it may be that one person in the treatment team picks up on signs that would alert the rest of the treatment team to a problem that needs to be addressed.
Team-Based Model of Care
We have a lot to learn from how providers of rehabilitation care provide for their patients. They work as teams, and often only a small part of the team are physicians. Social workers, physical therapists, occupational therapists, speech therapists, psychologists, chaplains, and others work together to address the patients’ needs.
These are complicated patients, often with more than one medical problem, so this is not a model for most patients. But what if we could identify high-risk patients? What if we identified those patients and could pair them with a multidisciplinary team to address the issues, better coordinate their care, and try to mitigate risk factors to avoid preventable complications?
With Amy Winehouse and Whitney Houston, alcohol and/or drug use was not unknown. Many people with drug and alcohol problems will not agree to treatment, and sometimes there may be little we can do for them. However, there are many others out there who could be helped if their support systems and medical care providers would come together to confront and address the problem.
Today’s model of care is not structured so that providers of care have the incentives to take time or make the effort to promote health or to attack the public health problems of people who are not identified patients.
Accountable care can create the right incentives. We can address health and prevention in such a way that we may be able to lessen the loss faced by families like the Winehouses, Houstons, and Jacksons. We can help save the lives of people who can then continue to make important contributions to their work, their communities, and the world at large.
David C. Pate, M.D., J.D., is president and CEO of St. Luke's Health System, based in Boise, Idaho. Dr. Pate joined the System in 2009. He received his medical degree from Baylor College of Medicine in Houston and his law degree from the University of Houston Law Center.