Physicians

The Future Is Calling Us

flying cadeuciiThe recent debate surrounding the American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) program is a microcosm for a transformation in medical practice that is long overdue. The profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice.  The solo-based practice is dying. As the ABMS program suggests, the awareness and acceptance of this shift is already occurring at the national medical board level, but it is not happening as quickly at the individual physician level. It is time for all clinicians to consider a new, more effective and more empowering approach to clinical care.

Let’s take a look at the details. As you may know, the MOC program consists of six Core Competencies for Quality Patient Care that physicians must demonstrate to maintain certification.  These competencies are over and above the traditional board certification requirements. The core competencies are professionalism, patient care, medical knowledge, practiced-based learning and improvement, interpersonal and communication skills and systems-based practice. Descriptions of each competency can be found here. In addition to being a new requirement, the program encourages a new style of practice for physicians.

The MOC program has generated considerable friction, especially among physicians, some of whom argue that the requirements place an additional burden on their increasingly burdensome work experience. Others have joined the program and are fulfilling its requirements. As of May 2014, 150,000 physicians were enrolled in the program, but tens of thousands have also signed protest petitions.

As the debate over the value of MOC illustrates, transformational journeys are difficult. Those who believe it ought to be easy can often end up confused and frustrated. Those who embrace it, despite some painful realities, find opportunity. The friction of change, the challenges we encounter in life, the ebb and flow of the unexpected, work together to help us see the future and our role in it. Friction can wear us down or help us to see a powerful new reality.

Regulatory requirements like the MOC program are a burden when they are layered on top of an antiquated system. The requirements are much less of a burden when the work environment allows them to be satisfied as a byproduct of work.  In recognition of this reality, the ABMS has allowed 32 major health systems, including the Mayo Clinic and M.D. Anderson Cancer Center, to satisfy some MOC requirements for their physicians via their existing quality improvement projects and programs. 51 additional health organizations are applying to do the same. These organizations allow physicians to satisfy the MOC requirements as they deliver care.

Working in an improvement environment can be an exciting and energizing experience for involved clinicians because the reform debate suddenly shifts to what matters most to them and their patients — the value and outcomes of care. It also allows participating physicians to satisfy MOC requirements as a byproduct of their work. It is no longer an add-on. It is what they do. To date, the ABMS health system arrangement has produced 529 quality improvement projects and more than 3,250 physicians have received MOC Part IV credit for their participation.

In creating these arrangements with health systems, the ABMS is tacitly implying that organizations with effective, data-driven quality improvement programs integrated into their care environments are the future of care. They are correct. Increasingly, more physicians will seek such an environment, if for no other reason than to improve their professional lives. The good news is they will encounter a better way to practice clinical care when they do.

Care has simply become too complex not to go in a new direction. As I stated, the profession of medicine is going through a fundamental shift from a traditional craft-based practice to a more sophisticated, data-driven profession-based practice that is centered on continuous improvement. This new environment implies that clinicians are operating in a highly supportive and rational care delivery and improvement system that allows them to optimally manage care processes while collecting data to support continuous improvement and learning.

There are signs of this change everywhere, not only within the MOC requirements. Most patients already have multiple physicians and dozens of other caregivers involved in their care. Accountable care delivery systems are being formed. Care delivery environments are increasingly supported by advanced information technology, including electronic health records (EHRs), decision support systems and analytic systems. The number of reported data-driven care improvement projects is growing exponentially.

These and other signs point to the fact that these trends are real, inevitable and lasting.  It’s time for us to embrace them. We need to simplify the environment in which we work and create an environment that will allow us to be the best we can be. The sophistication of the structure to support such an environment may be complicated, but that does not mean that the environment in which clinicians work need be. We need an environment that helps us better manage complexity, not one that adds to it. That is possible and it is happening.

With every major transformation, people strive to escape an unpleasant existing reality. Some do so by denying and resisting; others search for a better way. The latter are the achievers. They strive to get the job done. They do not ask simply “How can I get by?” and remain mired in frustration. Rather, they ask, “How can I solve this?” With the vision inspired by this question, they set out in pursuit of solutions. This is not merely activity, but activity driven by a deep sense of purpose. They have a commitment to excellence. They do the best they can to solve the challenges confronting them. Increasingly, they will succeed and those around them will recognize them as champions and leaders.

Listen to these pioneers. Imagine a new reality. The future is calling.

John Haughom, MD, former senior vice president of clinical quality, safety and IT for PeaceHealth, is a senior advisor to Health Catalyst and the author of Healthcare: A Better Way. The New Era of Opportunity.”

 

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Barry Goetz MDGranpappy YokumMichaelJohn Haughom, MDallan Recent comment authors
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Perry
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Perry

Preferably physicians over business people.

John Haughom, MD
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John Haughom, MD

The trend in ACO leadership doesn’t surprise me, but the numbers do. I expected this would happen because as healthcare moves toward payment for value, it is inevitable. I just did not expect it this fast. Value in healthcare is high quality, safe care at a reasonable cost. One cannot achieve value in healthcare without effectively managing the process of care and only clinicians can do that effectively and well. Even 80% of costs in healthcare are driven by a physician’s pen (I.e., our decisions). To achieve this, however, we will need to relinquish some of our individual independence to… Read more »

Perry
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Perry

“No doubt, we will see larger corporations delivering care in the future, but even they will not be successful in producing the outcomes we need without engaging clinicians in a responsible and meaningful manner. ”

Unfortunately, we definitely agree on this.

John Haughom
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John Haughom

I wouldn’t jump to conclusions too fast. I was pleasantly surprised by a recent study published in Health Affairs that showed physicians leading 50% of the emerging ACOs across the country and they co-lead in another 34%. Of course, being a physician does not necessarily mean you will be good at it, but I believe many will be. They understand and are likely to focus heavily on the process of care. Time will tell.

John Haughom
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John Haughom

Barry… Thank you very much for sharing your thoughtful comments. We are in agreement on many important points. While I do not know most of the board members behind the MOC, I do know a couple and I know their intent is to encourage physicians to engage in continuous improvement. No doubt, one could argue whether the MOC will help accomplish this, but at least in these instances, I know the intent was an honest one. As I indicated in my post, I understand that the MOC is a burden for many physicians. However, I also stand by what I… Read more »

Barry Goetz MD
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Barry Goetz MD

John, I feel your essay spans such a wide range of issues, and uses such overdetermined language, that the useful part of what you have to say is to a large extent overwhelmed. I found that the information about the integration of MOC into “learning organizations” and existing quality programs interesting and encouraging and far more forward thinking than I usually expect from the boards. (although it may be that the boards have realized they can extract more money from large organizations than individual doctors) Much of the pushback toward MOC has to do with the fact that the burden(cost)… Read more »

Granpappy Yokum
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Granpappy Yokum

The HealthCatalyst site is pretty revealing: another group of parasites scheming to divert health care dollars away from patients and physicians.

Paul Kempen, MD, PhD
Guest

John: Tell us a bit about your HealthCatalyst.com. Looking it over seems to indicate this is a company running down the federal tracks to implement “success” in EMR and other SCIP type programs for a profit. All about Data Acquisition-which means providing “big data” to prove god only knows what. What is the annual budget for HealthCatalyst.com? There are already so many such endeavors out there working for the Feds, why not just let the damn feds do it-after all they should be freeing up a huge computer system if we can shut down the telephone monitoring computers and put… Read more »

John Haughom
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John Haughom

William… I use Word to write my responses and Word’s “auto-correct” feature sometimes defeats my best intentions. The word “disciples” above should be “discipline.”

William Palmer MD
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William Palmer MD

I think we are doing fine, scientifically, in health care. And it seems access is on the way to being solved. Do you agree, John? The only other thing that needs a real change is costs and prices. There is a comparative health care systems researcher at UCSF who says that all the advanced nations are all doing about the same thing in health care. About the same results. She says the only differences are that we are paying our docs much more and our administrations much more. How does your book see these? Are there other huge faults in… Read more »

John Haughom
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John Haughom

From a scientific standpoint, I definitely agree with you. We have made remarkable progress over the past several decades, and there is much more to come. Due to the confluence of many scientific disciples, there are amazing advances just over the horizon in a number of areas including minimally invasive surgery, drug delivery systems, monitoring sensors, organ assistance devices, stem cell technologies, genomics, imaging technologies, 3D printing, tissue and fluid bioengineering, nanotechnology, mobile computing, robotics, regenerative medicine, remote patient management systems, telehealth, wireless technologies and information technology systems, to name just a few. The list of healthcare innovations on the… Read more »

John Haughom, MD
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John Haughom, MD

Allan… Sorry. I clicked “submit” before I meant. I appreciate your final comments. It is fine for us to disagree. The dialogue is what is important. We need more of it, especially among clinicians. I suspect I will have further posts. I will look forward to a continued exchange of ideas.

John Haughom
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John Haughom

Alan… Thanks for you willingness to discuss these important issues.

If you want to understand what I am advocating in more detail, I would encourage you to read my book. It covers the approach that I am talking about in great detail and includes many references. Anyone can get a free copy in PDF format at this link:

http://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way/

allan
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allan

John, I actually went to your site and scanned over a bit in a few chapters. Scanning doesn’t permit me to draw definitive conclusions, but it certainly demonstrated to me that your treatise is advocating a change or as you put it a transformation of healthcare and comprehensively managing the health… Perhaps you believe it to be advice to others to think about while they grow organically. However, it certainly doesn’t sound that way. It sounds as if population groups need to be managed a certain way or else what? Coercion? From who? That is the big question. You also… Read more »

John Haughom, MD
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John Haughom, MD

Alkan… Rather than scanning the book, I would encourage you to read it. Healthcare faces serious challenges and it will take creative ideas to solve them. I certainly do not presume to have all the answers, but I have been fortunate to encounter many visionary healthcare leaders – mostly clinicians – who are being very innovative. Anyone is free to reject their ideas, but if they do, I would respectfully suggest that they are obligated to offer better solutions.

allan
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allan

John, we have scarce resources for many things and time is one of them. I have learned to scan just enough to see if I need continue. I don’t disagree with many of the methods used by others in a free marketplace and was quite familiar with most of what I read. The methods are not at issue. The issue revolves around change and how that change occurs. Will coercion be involved or not? That important aspect of change was left out of your treatise or at least the parts I read. Once coercion is used all sorts of bad… Read more »

John Haughom
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John Haughom

Alan… I am not a big fan of criticism. Criticism alone rarely works, especially during major transition periods like the one healthcare is going through right now. What healthcare needs right now is a new vision. We need solutions. I encounter clinicians constantly who are looking for a new vision; one that offers them hope. One that captures their imagination. Thus, the book is heavily focused on solutions that will empower clinicians and offer them hope. It is easy to do a word search in a PDF document. Do a word search on “engagement,” “front-line clinicians,” or “smart cogs” (referring… Read more »

allan
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allan

“ I am not a big fan of criticism” Neither am I, but jumping at the unproven can make things worse. You know that as a physician. Healthcare might need a new vision, but as we have seen with the ACA these new visions don’t necessarily work as expected and don’t suddenly make all the bad disappear leaving us with goodness. Our discussion is not about any particular method or solution rather how a solution should be implemented. With coercion or without. That is where we differ and that is the essential difference between top down control and organic growth.… Read more »

William Palmer MD
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William Palmer MD

I bet we’ve had a hundred ideas tossed at us-all telling us how to improve–since Obama declared our profession a disaster in 2009. Many are laughably contradictory: how can we have coordinated care up the gazoo in a medical home model and yet espouse hospitalists at the same time–who can barely remember the patient’s name? How can a movement not want big deductibles for HSA plans and yet bring in outrageously low actuarial value plans where cost sharing is enormous?…going so far as suggesting a copper plan with a 50% AV plan ( meaning 50% OOP). Apparently it’s ok to… Read more »

John Haughom
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John Haughom

I certainly agree that the solution to the challenges facing healthcare is not top down. The beauty of modern improvement theory and methods is that it argues that the problems facing complex organizations can only be solved by its front line workers — so-called “smart cogs.” Healthcare and healthcare organizations certainly qualify as complex, and our “smart cogs” are clinicians. I believe healthcare has the most intelligent, well educated and committed workforce in the world. They are the solution, not the problem. However, in order to play this role, we need to collectively embrace new ideas and engage. A growing… Read more »

allan
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allan

Since so many of the leaders like Mayo differ in so many different respects as to process and a whole bunch of other important things how does one follow the leader?

The answer is from bottom up individually picking out those things most valuable to those at ground level. That means that collectives or organizations that tell others what to do (suggested in your blog) or think on the micro level are the ones that are inhibiting positive change.

John Haughom
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John Haughom

When I advocate for healthcare’s smart cogs — clinicians — as the solution to the problem, I am arguing for a “bottoms up” solution. I am very familiar with organizations like Mayo and Intermountain. They are not top down. Their clinicians design the care that patients want and need. In my book, I argue that very healthcare organization (e.g., health system, physician group, or hospital) can emulate this, even if they are not a Mayo. It is the methods I am advocating, not the organizational structure. My point in highlighting these organizations is that they have demonstrated that the methods… Read more »

allan
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allan

Methods and process are similar in many respects. I said these leaders you mention have many different processes. I will add many different methods as well. ” It is the methods I am advocating” Methods differ in all of these different organizations. We all learn from the experience of others, but for the methods and processes to grow organically you have to leave things alone and let them develop in their own fashion. Mayo didn’t have top down control to create Mayo. By advocating the use of Mayo’s methods or the methods of others it sounds like you are using… Read more »

John Haughom
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John Haughom

I am advocating the use of modern improvement techniques. The physicians in those organizations are all using the same methods and tools and producing outcomes characterized by higher quality, safer and more cost-effective care. How they organize to achieve those goals does vary, but that can lead to innovative new approaches for others to emulate. It may sound like a top-down approach, but it is not. Clinicians who get engaged in this type of work are very empowered. I have seen it many, many times. Also, I don’t want to focus on just these organizations. There are hundreds of other… Read more »

allan
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allan

John, you say you are advocating. Whether the techniques are modern or not doesn’t change the nature of the advocacy. You sound as if you are using a top down approach. That those methods from these other institutions improve anything in a different situation isn’t proven. In fact there are many techniques that differ from center to center. One technique that works in a high quality center might not work in another one. In the individual organizations such as Mayo physicians might be using the same methods, but from organization to organization those methods differ. I don’t know that one… Read more »

William Palmer MD
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William Palmer MD

I’m sure you are trying to help the profession, John, but this MOC idea is too forcing and top down, tries to cookie-cut our knowledge, necessarily leads to group-think, and is distracting everyone from his/her own interests. Besides, medicine is still half art and our true science is never settled enough for educational pronouncements from on high. It’s rather like requiring an artist or musician to be re-certified. This is a little hyperbolic, I admit, and I can see the need for docs to keep up on legal requirements and legislation, but you don’t want to negatively interfere with the… Read more »

John Haughom
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John Haughom

The evidence is very strong that hospital care is very expensive and we need to use it only when appropriate. There will always be a need for hospitals, and with our aging population, most of them will stay very busy. However, there are also some very exciting technology-enabled models of care that many organizations are currently studying in the US and Europe. These care models allow clinicians to be more proactive in their care, to be manage larger populations of patients efficiently and well, to empower patients and families (the largest untapped healthcare force in the country), and to lower… Read more »

Perry
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Perry

“We are also too hospital-centric and need to develop technology-enabled care models that are more ambulatory and patient centric. ”

This, I see as a huge problem, and not likely to result in either better patient care or lower costs.