You’re right, Dr Hatch. Nobody’s feels like they’re winning. Last week I was in a room with a group of physicians, and the Chief Medical Officer of an ACO was explaining to them that he could give them all dashboards that they would love.
But the physicians didn’t look like they were dreaming of the same valentines. “What would we do with a dashboard?” Said one. “Is this another Meaningful Use requirement gone bad?” Said another.
The undertone is that “we didn’t sign up for this population health” stuff. Physicians are intellectually challenged by, and find meaning in the personal conversations and diagnostic puzzles that are well represented in caring for individual people. We are not intellectually challenged by the need to remind patients to get a colonoscopy, mammogram or flu shot.
Two decades ago, David Slawson and Allen Shaughnessy introduced the concept of POEMs and DOEs to medical educators as a way for us to help students distinguish between important and unimportant medical literature. A POEM is a paper that expresses Patient Oriented Evidence (that) Matters. An example might be a study that demonstrates that patients who eat fewer hamburgers will live longer lives. A DOE is Disease Oriented Evidence: a study that demonstrates that a given finding or intervention is associated with an intermediate outcome that we hypothesize will lead to better outcomes. The study that shows a statin medication lowers cholesterol (but doesn’t reduce heart attacks) is DOE. When teaching medical students, I would offer an easy way to discern DOE from POEM: ask if grandma would understand the guidance, and be able to act on it herself. Eating fewer hamburgers extends life? Check. AmazingStatin Lowers LDL Cholesterol? Nope.
The way that “population health” is being promoted today makes the same mistakes that a third year medical student who doesn’t understand the DOE/POEM distinction would make: based on an incomplete dataset, we offer guidance/decision support/recommendations, or “care gap reminders” (all synonyms – all flawed) to harried providers who are already having a hard time keeping their noses above water.
Just as patients are resisting, so too are the physicians, and for similar reasons:
- All people want to feel autonomy. We want to understand what’s really best for this person – not this segment of the population. We don’t trust a computer to tell us what to do.
- We need to focus on the root causes – and the solutions to THOSE problems, rather than checking a box to satisfy an algorithm. Does depressed patient with diabetes and hypertension need a prescription for medication? Or do they just need a prescription for exercise? Population health products and processes guide us toward the former. Most would agree that the latter would be a better answer.
But all is not lost. To get out of this care cascade, we first need to change the way we talk about the solutions. We don’t need population health platforms. We need personalized, proactive health management tools. We can use these tools to initiate a conversation between the care team and the individual. We can use these tools to develop insight into the patterns of care that are most associated with health, and the patterns of care (and living) that are less associated with health. Instead of a dashboard aimed at the physician – showing where we have failed – perhaps a shared view of a patient’s spectrum of opportunities would emerge. With this shared view, a patient can identify health goals, and the physician will now (finally) be engaged with the patient. Full circle: patients and care providers collaborating (rather than resisting) toward shared success. Guidelines, POEMs, and data are all essential parts of this picture, but the product is an elegant facilitator of shared decisions rather than a control interface for the captain.
So I’ll end where you did, Dr Hatch: let’s stop this Sisyphean work on “population health,” and shift our focus to personalized proactive health!
Jacob Reider, MD is the CEO of the Alliance for Better Health