Delivery of Care

Caring for the whole person, with messy human relationships

How the rapid adoption of telehealth as a platform in the delivery of health care is redefining the office visit and the future relationship between patients and providers

Photo by Richard Asinof

The billboard off Route 195 reads: "Social distancing won't lower your cholesterol. Don't put your health on hold," a chiding message targeting patients. How would billboard advertising change if and when health care delivery systems were organized around what the patient needs and wants, not what the provider and health system desire.

Image courtesy of Jill Duncan

Jill Duncan, executive director at the Institute for Healthcare Improvement.

By Richard Asinof
Posted 9/14/20
An interview with Jill Duncan, the leader of a workgroup advocating for systems change in health care delivery around putting the needs of the patient first in redesign of health care in a post-pandemic world.
How does health equity become part of the conversation around the evolution of telehealth, digital health, and future design of health care delivery? What kinds of new data platforms need to be developed to measure the needs of patients and to promote empathy, not efficiency? How many hospital CEOs are willing to go on furlough to help save money at their health systems? How effective are the health system billboard campaigns urging residents to go see their primary care providers? What are the connections between gun violence and domestic violence? What happens when a patient disagrees with a doctor and says no?
Much has been made of the results of the recent primary election in Rhode Island, attempting to analyze why many progressives challenging incumbents were elected – citing grassroots organizing, overconfidence by incumbents, and the general angst caused by the coronavirus pandemic. What has been left out of the conversation by pundits and political reporters, surprisingly, is the way in which health care played an important role in how voters responded to successful candidates, and how that resonated with the issues that mattered most to them. Missing from the analysis of state Sen. Sam Bell’s victory, for instance, was how his advocacy on behalf of his constituents, raising questions about the state’s policies around Medicaid, proved to be a winning issue for him. Why is that?

PROVIDENCE – Call it a moment of Zen, a serendipitous encounter, with profound resonance. Eight years ago, on May 22, 2012, a bevy of national experts came to Rhode Island to discuss how best to grow patient-centered medical homes, at a “think tank” gathering hosted by the Warren Alpert Medical School at Brown University.

In the audience that day were many of Rhode Island’s top echelon of health care policy experts and poobahs – R.I Health Insurance Commissioner Christopher F. Koller, Lt. Gov. Elizabeth H. Roberts, Rhode Island Quality Institute President and CEO Laura Adams, and Dr. Michael Fine, director of the R.I. Department of Health, all of whom have since moved on to different positions.

At the talk, the experts presented a strong challenge to the current way of doing business within the health care delivery system, detailing examples of successful patient-centered medical homes in Alaska and Vermont that had transformed the business of health care. [It was unclear how many, if any, of the Rhode Island health policy experts in the room were paying close attention.]

Dr. Douglas Eby, the vice president of Medical Service for Southcentral Foundation, Alaska Native Medical Center, talked about the importance of ‘preparing the soil” in order to grow a successful model of health care delivery.

Instead of organizing around the needs of the provider, with an emphasis on tests, diagnosis and treatment, Eby’s Alaska health care model changed the emphasis to a customer-owned model, defining health care as a longitudinal experience, with “messy human relationships in play all the time.”

The results achieved by Eby’s model of health care over the last decade included a 50 percent drop in urgent care and ER utilization, a 53 percent drop in hospital admissions, a 65 percent drop in specialist utilization as well as evidence-based generational change in reducing family violence.

The shift to delivering health in a community context, rather than “disease care,” involved changing the workflow patterns. It began with learning to listen “at least 10 different ways at all times,” an investment in mentoring for all clinicians and management, and a way to “re-humanize” the story, re-defining care for a defined population.

It proved to be a seminal moment for Dr. Patricia Flanagan, a pediatrician who sitting behind ConvergenceRI at the talk, who wondered out loud: “Why just adults? Why not create a similar model of patient-centered care for kids?” All of the recent investments, she told ConvergenceRI after the talk, have gone to identify potential cost reductions in chronic care for adult populations, with little focus on children.

That insight provided the spark, as Flanagan went on to launch PCMH-Kids, part of the all-payer Care Transformation Collaborative. [See link below to ConvergenceRI story, “The art of coordinated health care when it comes to children.”]

Eby’s watchword for his providers – that they needed “to learn to listen in at least 10 different ways,” in order to be able to “re-humanize the story” – also proved to be one of the critical catalysts for the launch of ConvergenceRI on Sept. 23, 2013, seeking to create a source of accurate, in-depth news reporting that attempted “to listen in 10 different ways” in covering the convergence of health, science, innovation, technology, research, education and community.

What Eby had described as a remedy for the dysfunction in the health care delivery system also offered a remedy, in ConvergenceRI’s opinion, for much of what was wrong with news reporting around health care and health equity in Rhode Island.

Evolution from dinosaurs
Fast-forward eight years. Eby has continued to push forward his efforts to change the health care delivery system to a more patient-centric, customer-focused enterprise. He was the co-author of a recent article in Medium, with the provocative headline: “COVID Has Made the Office Visit a Dinosaur.” [See link below to ConvergenceRI story, “Warning: Speed bumps ahead.”]

The story was written by the Boston-based Institute for Healthcare Improvement leadership team, which included Eby, Dr. Edward McGookin, Chief Medical Officer at Coastal Medical, and Jill Duncan, RN, MS, MPH, executive director at the Institute for Healthcare Improvement.

The article began: “The office visit has been central to modern medicine. Long-held truths include the necessity of meeting with patients in person, lining up patients to see them in order, and care team members efficiently doing their part to maximize the physician’s precious time and skills. COVID has shown that this choreography is often unnecessary.”

The onslaught of the coronavirus pandemic has exposed how unprepared the nation’s public health and health care delivery systems were to respond, challenging most of the underlying assumptions about in-patient care, pushing the adaptation of telehealth platforms from a novelty to a necessity. [See link below to ConvergenceRI story, “From a novelty to a necessity.”]

The coronavirus pandemic has also exposed the financial frailty of the unsustainable business model pursued by health systems in Rhode Island [and elsewhere], with hundreds of millions of dollars in federal funds required to pump up the two major health systems, Lifespan and Care New England, prompting them to re-consider an arranged marriage. [See link below to ConvergenceRI story, “In search of a sustainable business model.”]

What it has not necessarily done, however, is forced the hospitals or regulators to confront or recognize their own moment of Zen – to take the opportunity of the COVID-19 crisis and re-imagine how care is delivered, with an emphasis on patient, not provider, needs.

ConvergenceRI recently had the opportunity to speak with Jill Duncan, RN, MS, MPH, executive director at the Institute for Healthcare Improvement, the co-author of the provocative Medium article, and one of the leaders of an ongoing workgroup that is exploring and promoting systemic change in health care delivery, what Duncan called “truly transforming the care delivery experience to be completely woven around the patient.”

In all of the talk about the redesign of the office visit as part of the transformation of health care delivery system change, Duncan told ConvergeneRI, “Understanding what people want and need, when, where and how much they need, it is all hinged on the assumption that we have a relationship with people.”

Here is the ConvergenceRI interview with Duncan, a deep dive into the forces driving system change in health care delivery, which provides an insightful way to launch a new year of convergence and conversation in Rhode Island.

ConvergenceRI: I thought that labeling office visits as a “dinosaur” was pretty far out there. Could you talk about how you see the evolution of health care occurring?
DUNCAN: Let me begin by offering a little bit of context. The Leadership Alliance is a network of executive leaders from 53 very progressive health care delivery systems.

They work together, year after year; this is the sixth year of the Leadership Alliance, and the community alliance members put forward key themes that they want to collaborate around.

We call them workgroups within the network; they are co-led by members. In this case, Dr. Doug Eby, in particular, put forth this idea and it has been something that Doug been pushing on for years, truthfully, within the Leadership Alliance – the notion of truly transforming the care delivery experience to be completely woven around the patient.

He has been advocating within the Alliance to make progress toward redesigning systems that are primarily driven by what works optimally [best] for the patient.

We call it “time, place, and mechanisms,” basing our work on weaving our expertise, partnering skills and abilities into [the patients’] lives, on their terms.

That is really at the ethos at the Southcentral Foundation [and the Alaska Native Medical Center], at which Doug [has served as] chief medical officer and senior leader for more than 30 years.

If you are familiar at all with Southcentral, you are perhaps aware that they are a two-time Baldrige Award winner. [The Malcolm Baldrige National Quality Award is an award established by the U.S. Congress in 1987 to raise awareness of quality management and recognize U.S. companies that have implemented successful quality management systems. The award is the nation's highest presidential honor for performance excellence.] They are the only health care delivery system to be a two-time Baldrige winner

They have built a health care delivery system around their strategic obsession with what works for patients, and learning to listen and to understand what that means, in a way that is truly unparalleled.

There is movement of consumerism in so many aspects of health care in our world today that is the threat or the disruptor to traditional health care systems. We hope in some ways to use it as a bit of an impetus to this work.

ConvergenceRI: Can you describe what that work is?
DUNCAN: That is long introduction to say, this working group was an idea within this network for many years, and last fall, we formed the group officially. A number of health care delivery systems are working and learning together toward that common aim.

[As a goal], we said that by Sept. 30, we would all make progress toward redesigning our systems in those ways. And we’ve looked at [metrics], such as clients’ report, to make sure that they get what they need, how they get information, services and support when, where and how it works well for them.

It is designed as a patient-centric, not a provider-centric system – [the concept that] patient time and effort are held in high regard and as an irreplaceable resource. And, we look at the percent of interactions [that occur] in person.

There are assumptions within this system redesign that there is an opportunity to think about when – and how – we need to touch and see patients in order to care for them.

Many of these aims aligned with telehealth services. And, of course, COVID pushed the accelerator on all of that.

ConvergenceRI: Can you delineate what you meant when you talked about the differences between patient-centric and provider-centric practices? I have heard a lot of “rhetoric” around patient-centered medical homes. But I am not sure whether they reached the point of realizing that they were still mostly organized around provider needs, not necessarily patient needs.
DUNCAN: That’s not something this group has fixed, but it’s something that this group has acknowledged and has really grappled with. We have suggested, coming out of COVID, that there are really two directions to go, if we are going to talk specifically about [scaling up] telehealth.

Telehealth scale can either be an extension of the provider-centric model that uses telehealth in that way, or it can be thinking about what are the systems that would need to change in order to allow that platform to improve patients’ ability to get what they need, how they need it, and when and where they need it.

I would love to say that we have deep examples of [transforming] the system between provider-centric and truly being patient-centric. I think we have examples in the network that are emerging. But it is the reality that we are still very much pushing [the envelope] in this workgroup. This workgroup recognizes that there is still tremendous work to be done to look at what system transformation means around the patient.

How do we know when we are making progress? We can count things like virtual visits. We can count things like patient experience. But we have struggled in this workgroup, and we are continuing to push and challenge each other, to really look at how our vision is being driven by what the patient wants – when we talk about going back to in-person visits or using virtual platforms, when we talk about patients getting what they need in real time, when we talk about the integration of person-driven systems such as AI and machine-learning, and how does that work and integrate within systems [of care].

Those are the things that we are learning together as part of this working group.

ConvergenceRI: You trained as a nurse, is that correct?
DUNCAN: Yes, I’m a nurse by background.

ConvergenceRI: Often, I feel that the current health care delivery system has been oriented around by what doctors want, and the perception that doctors drive the system. Yet most people that I talk within the health care delivery system will acknowledge, if they are being honest, is that nurses are the ones that drive the system. If women hold up more than half the sky, nurses hold up more than three-quarters of the health care delivery system.
But, nurses are often left out of the equation in decision-making. Is part of the transformation of the system of care you are talking about include a way to enable nurses to play a more active role in redesigning the system of care delivery?
DUNCAN: I do. I think there is a different role emerging for nurses. I think there’s a different role for physicians, and there is a different role for the rest of the care team, and that includes the family and community care team.

There are of couple of principles that we have talked about that are specific to theory of the office visit as a dinosaur. There are four of them that fall under the bucket of aligning, training and retaining the workforce.

The first is: resetting the physician leadership and team-based whole person care paradigm. That idea is to suggest that physicians have a very different role, it’s more like consultative, supportive team member, rather than serving as a center of excellence.

That is a different model for the design of care delivery; it’s a different model for training, for [recruiting] a workforce that is willing and interested in partnering in that type of work dynamic.

I think it is different way of working [than the way than] most traditional practices [operate] right now. We’ve also talked about [the concept of] developing family and friends as skilled service providers. Also, optimizing community-based workforces, and community health workers. Safety-net providers are probably the greatest example of that but there are others as well. And that is design element that we’ve suggested needs to be a part of this care transformation.

ConvergenceRI: Have you received pushback from health insurance companies about this effort?
DUNCAN: A number of the members of the Alliance have a payer arm. So they have, very successfully, been able to align more of their risk within their system design.

ConvergenceRI: So much of the conversation around redesign of the health care delivery system gets down to the dollars-and-cents issues: who gets paid, when, for what, and how much. Much of that is determined by how episodes in the health care delivery system are coded. Not only have doctors but insurers have gotten very comfortable with the status quo of the existing system.
By disrupting the office visit and the patterns of staffing and behavior around that, you are disrupting the way that insurers pay out claims. What kind of dialogue may need to take place with insurers to get them on your side?
DUNCAN: That’s a great question. We have two insurers that have been participating in this work. Humana is one and the other is SCAN Health Plan in California [a not-for-profit Medicare Advantage health maintenance organization in Long Beach, founded in 1977].

This is an area that we haven’t pushed as hard on within the workgroup as we need to. I think we do need to continue to come back to a deeper understanding of what at-risk contracting allows, and what does that look like for different systems. It is not a place to date that this group has focused their emphasis. But it is the reality, you are right.

ConvergenceRI: Part of the disconnect that occurs between patients and doctors in an office visit, whether in-person or virtual, is the way that the flow of information is defined and constrained by having to ask and answer ridiculous question, in my opinion, such as: What is your pain level today, on a scale o 0-10; how much pain are you in?
It seems to me, until you can change that kind of question and the way it is asked – as a perfunctory metric to fill out a box on a form, you are not going to be able to engage with the patient in a more meaningful fashion.
DUNCAN: Yes. Part of the way that we have engaged with this workgroup is to agitate on some of those same issues, to push and raise the questions. And, absolutely, to the degree that we maximize the use of patient portals and telemedicine, at all levels, to examine what questions are necessary.

There is quote that sticks with me from one of our first conversations [in the workgroup] that was from a chief information officer from a large integrated health system, saying: “As a patient, act like you know me; act like you know me when I come into your system.”

If we design around that question, if we design around that assumption, we think differently about the ways we ask questions and the questions that we ask.

It may require us to redesign our electronic medical record so that there are not the same prompts that require greeting patients [and asking questions] in order to get to the next field [as quickly as possible].

It challenges the way we use waiting rooms, it challenges the way even bring people into our clinic or office space, and what happens when we do bring them in.

These are all questions that this working group is testing right now, in different settings, in individual ambulatory settings within systems, in ways that they can push the boundaries, in order to learn and understand what [patients] come up against.

ConvergenceRI: Two years ago, the president of Epic, Carl Dvorak, spoke at the Warren Alpert Medical School. He talked about developing an AI system that used de-identified video to capture how patients and doctors interact.
Which really angered a physician, who pushed back at Dvorak, arguing that the most important feature of a patient-doctor relationship was trust.
For all the work that is being put into AI, to be able to use algorithms to predict human behavior to create better health outcomes, particularly as the popularity of wearable devices surges, what is the role of empathy in health care?
DUNCAN: One of my first thoughts is that there is a gentleman whom we listen to within this work group – Dr. Saul Weiner, at the University of Illinois in Chicago. Weiner has written quite a bit about using simulated patients, almost like “secret shoppers” within the health system, to try and better understand the quality of care and the aspects of the experience of care.

We are still in the coronavirus pandemic crisis, our workgroup has talked very specifically about the transition to telehealth; we’ve talked about how many systems were saying, patients just want to go back to in-person visits, and providers want to go back to in-person visits.

It has raised the opportunity to ask the question: what was it about the experience within the virtual experience, to make it a more desirable experience for patients and providers. It is a simple question about the continuous improvement around telehealth, but it does get at the feeling of people feeling cared for.

I feel as if I am channeling Doug Eby. He says it all comes down to the relationships that we have with people.

We are living in interesting times, with technologies that are popping up, there are chain stores with clinics in an attempt to meet consumers with the convenience they want.

Post pandemic, the relationship we have through our primary care providers is at the heart of our ability to care for the whole person.

In all of this talk about the redesign of the office visit, we have to talk about structures, understanding what people want and need, when, where and how much they need. It is all hinged on the assumption that we have a relationship with people.

ConvergenceRI: Imagine if the provider asked, instead of pain scale question: What was the best thing that happened to you today? Would that change the dynamics of someone listening to what had happened in a patient’s life, to listen to something they felt good about?
DUNCAN: I’m going to ask that on my next virtual call. So thank you for that prompt.

© | subscribe | contact us | report problem | About | Advertise

powered by creative circle media solutions

Join the conversation

Want to get ConvergenceRI
in your inbox every Monday?

Type of subscription (choose one):

We will contact you with subscription details.

Thank you for subscribing!

We will contact you shortly with subscription details.