Innovating for multimorbidity

Most people who consult doctors in primary care have more than one problem. The proportion of people with so called multimorbidity is set to rise exponentially as the proportion of older people in many countries rises. The problem is that the length of consultations is limited and therefore the patient and practitioner are already at a disadvantage before they begin. Do you focus on the rash which the patient is anxious about today and which may be the beginnings of eczema, or the hypertension which isn’t at target despite therapy, how about the cigarette smoking and the aching hip and to what extent does the chemotherapy treatment in the past have a bearing on the fatigue that the patient has complained about in the previous consultation. In theory consultations can be extended for patient with greater need, assuming that the need is expressed. According to one team:

Approximately 9% of the patients had 1 or more unvoiced desire(s). Desires for referrals (16.5% of desiring patients) and physical therapy (8.2%) were least likely to be communicated. Patients with unexpressed desires tended to be young, undereducated, and unmarried and were less likely to trust their physician.

Bell et al JAMA 2001

The bottom line is that there is significant unmet need. In theory, in many countries the general practitioner has a longitudinal relationship with the patient and will eventually get around to some of these other issues.  Even in those countries that espouse the concept of  primary care as the first point of contact for people with the healthcare system, the reality is that people tend to consult more than one GP, either by choice or because they have no option and therefore continuity of care is theoretically possible but never actually achieved. The consequences include poor outcomes. It’s even worse in the specialist sector where regular turn over of junior staff means that people seldom see the same doctor from visit to visit.

Here is an opportunity for lean innovators to proactively screen people with a specific problem- for example all patients who have been treated for cancer attending a practice or by offering people an opportunity to have their needs met in another way– either by empowering self care or by enlisting the support of a nurse or allied health care provider. People in distress who are in contact with healthcare organisations cannot be left to fend for themselves or allowed to live under the impression that a diminished quality of life is the best that is now on offer.

Innovation doesn’t always have to mean new

In a world of new gadgets and gizmos we have lost sight of the fact that medicine is a social construct and that there have been some extraordinarily successful doctors who never ordered an X-ray or prescribed penicillin. That does not mean to say that X-rays or antibiotics don’t make us better healers but if we lose sight of the reasons why people have always needed doctors then we face a very uncertain future. In the world of business it is recognised that people buy ( i.e. make decisions or commitments) based on how they feel about something, not just, and sometimes in spite of , the information available. Heart always trumps mind. How else do you explain so many of our questionable decisions in life? By corollary we need to invest in the experience we offer as health care providers, perhaps more than the devices we chose to purchase that keep us at arms length from the patient.

What that means for innovators is that we occasionally have to rediscover the ‘innovations’ that are already in our offices. Possibly the most celebrated research I led was a study that demonstrated that people trust you more when you are seen wearing a stethoscope. It followed on from research that confirmed other things we have ‘always known’- what you wear matters, how you greet your patients/ clients matters and if you seem distracted in the consultation then it detracts from the patient’s experience.

At medical school one of our tutors offered this advice:

Always stand to greet the patient, never sit down before the patient and always find a reason to touch the patient even if it is only to take their pulse.

Simple advice that speaks to the art of healing- because in the end that is what gives medicine its mandate to be involved with people in distress. We were reminded that for some of our patients, perhaps those who need us the most, the unemployed, the marginalised, the unfortunate  the doctor may be the only person in any authority who will greet them with respect that day. Therefore innovation begins and ends with a review of the basics- What is it like for your patients or clients? How are they welcomed to the service? Is your telephone message welcoming? Are your reception staff professional? Do you offer privacy at all times? Do you seem interested or concerned? Would you trust someone who presented themselves the way you do?  Would you feel better after a visit to your clinic? Do your staff need a new machine more than a better way to make people feel they care?

Innovating to save precious time

When I was at medical school Pendleton’s book on the consultation was required reading. Pendleton maintained that one of the tasks in the consultation was to consider ‘at-risk factors’. It’s one item on an otherwise long list of tasks to be completed. Today it is often the case  that a discussion of  those ‘at-risk factors’ take over the focus of the consultation. Doctors are urged, even rewarded for moving the agenda to- diet and exercise, responsible drinking, colorectal, breast and cervical screening, hypertension, safe sex….the list is endless. The impact of having the doctor’s agenda up front and central in the consult is what has been described as

High controlling behaviours.

Ong et al.

The resultant style of consultation is described thus:

It involves… asking many questions and interrupting frequently. This way the doctor keeps tight control over the interaction and does not let the patient speak at any length.

Recently medicolegal defense organisations have taken to issuing advice against this pointing out that when the patient does not feel they have been heard they are more likely to complain. Research has shown that patients don’t ask for much. They won’t take long to spit out the reason for their visit. In one study:

Mean spontaneous talking time was 92 seconds (SD 105 seconds; median 59 seconds;), and 78% (258) of patients had finished their initial statement in two minutes.

Langewitz et al.

Allowing the patient to speak first is a good start. Then how do we support practitioners to earn a living by also attending to those topics for which they must tick a funder’s check box? Tasks introduced by policy makers as if the primary care consultation was replete with redundant time. In some ways it’s like what happens when you buy a new television, it’s not long before the sales assistant wants to sell you insurance and other products- ‘just in case’ but really because their commission depends on it. What we need in medicine is to stop eating into the time it takes to explore a patient’s ideas, concerns and expectations, time needed to examine the patient and express empathy. We need cheap, agile, intuitive and creative solutions that will quickly offer the patient an indication of their risk from whatever the latest public health issue happens to be- smoking, influenza, prostate cancer…but also the benefits and why they might want to consider ‘taking the test’, accepting ‘the jab’, or changing the habit.  My colleague Oksana Burford invested three years testing one such innovation. What Oksana realised is that in the end it’s the patients choice and the key is to introduce the idea of change in a way that speaks to her but only when she is ready to hear the message.

The reasons why primary care is selected to relay public health messages is that people trust their health care provider and are more likely to comply if that practitioner recommends it. However that does not mean that we should assume the patient can only get the necessary information from one source. What the practitioner can do is sign post where that information can be found and effectively convey why the choice being recommended is better than the status quo. I recommend the food swap app– its downloaded free and saves a lot of time which can then be used to deal with the reason the person had come to see me in the first place. There is lots of room for innovation but it should meet the needs of the patient and the practitioner.

Integrating primary care providers

People can, and do, consult other than doctors when they are unwell or perceive that there is something the matter with them. The list is large but includes:

  • Pharmacists
  • Nurses
  • Podiotrists
  • Dentists
  • Physiotherapists
  • Opticians

These care providers offer  a specific skill set but this does not include the ability to deal with undifferentiated conditions or to make a definitive diagnosis of a condition outside their scope of practice. However research suggests that such primary care professionals are often among the first to treat someone with depression, cancer, atheromatous vascular disease, hypertension and or dementia. Early diagnosis and treatment of any of these conditions would result in a much better outcome for patients. That does not mean that these health care professionals could or should be a substitute for medical practitioners. For one thing their business model does not allow them to spend time on dealing with the complexities that are inherent in establishing a diagnosis of such conditions, or to deal with the many others that need to be ruled out in the differential diagnosis. Nor are they equipped to coordinate the care of people with such conditions.

Cheap intuitive and creative solutions include ways to signpost people who present with such problems to the care professional best placed to coordinate their care. Research suggests that when someone is offered a note to present to a medical practitioner suggesting investigations for significant pathology, people will follow up with an appointment and benefit. The components of such an innovation include a way to screen people for risk of significant pathology- the person with persistent diarrhoea seeking advice from a pharmacist, the person with unrelenting back pain who might be clinically depressed, the person with undiagnosed diabetes presenting with visual problems. All these people need to consult a medical practitioner. However they are not always recognised and here lies the scope for relatively cheap innovation to integrate care providers without interfering in the way care providers function within their own domain of expertise.

Managing demand for primary care

Why do people consult doctors? At first glance because they feel unwell. However research suggests that the reasons are far more complex than that. Innovators also know that the answer to this question is vital for those seeking an agile, intuitive, creative and cheap solution to the demand for their services. Theories predict the consultation habits of many patients. I especially like this summary:

The overall prevalence of symptoms in the community is not closely related to general practice consultation rates, and the consulting population is a selected population of those who are in need of medical care. The literature reviewed suggests that poor health status, social disadvantage poor social support and inadequate coping strategies are associated with higher consultation rates. Some populations subgroups may experience particular barriers to seeking care. Campbell and Roland

Innovators might also ask why are those patients sitting in my waiting room? I remember a hoary old tale of a doctor who was feeling especially grumpy one day and stormed through the waiting room announcing that anyone who thought they had a ‘real’ problem should stay everyone else should go home- half the waiting room emptied.

It seems quite a few people who go to doctors will have symptoms- however a proportion will be back there by invitation. How big a proportion and why have they been invited back? There are many reasons to schedule a repeat appointment. It conveys the notion that the patient will be harmed if they don’t see a doctor on a given day for one or more of these reasons:

1. Their response to treatment is unpredictable and the dose or drug may need to be revised

2. They have a condition that can’t be diagnosed or may progress or need additional measures by a specified date

However other reasons for requesting a review include:

1. The doctor isn’t confident that the diagnosis is correct and wants a chance to review the advice issued.

2. The patient is required by someone (e.g. an employer) to produce evidence of a visit to a doctor

3. A full waiting room ensures the doctor looks busy for whatever other reason.

4. The doctor needs to reinforce the impression that the condition has been taken seriously.

The time cost for doing everything that could possibly be recommended for patients with chronic conditions  has been shown to be untenable. Either the guidelines are wrong or a different solution needs to be found for at least some of these people. What is the evidence for asking a patient to return within a week or two with a specific new condition and within a month with a longstanding condition?

There is a need to be proactive in some cases. However is it possible that we encourage people to attend for review appointments when there is a low probability that they will benefit? Are there other reasons to fill the waiting room?

The most successful health innovation ever

What medical innovation is:

1. Available worldwide
2. More likely to yield a diagnosis than an X-ray
3. Cheaper than the cheapest stethoscope
4. Requires less training to operate than a tendon hammer?

Answer: A tongue depressor

Why? Because when deployed within the context of a medical consultation- when the practitioner gives the patient their undivided attention, the tongue depressor forges a relationship that may lead the patient to express their deepest concerns. In what other social context can you shove a piece of wood into someones open mouth and get them to say ahhh? A few years ago I consulted a fifty year old mother of five, working as a supermarket check out assistant complaining of a sore throat. We talked about how awful she felt and how she was struggling to cope with her job, how she gets frequent bouts of tonsillitis and how she was afraid her boss would sack her. She had a mildly red throat and I thought I could feel a couple of tender lymphnodes in her neck but her temperature was normal and I remember thinking I’d seen worse earlier that day. Then as I turned around to write a prescription she burst into tears and said-

‘There’s something else I need to tell you doctor. I’m now working as a prostitute because for the first time in ten years I haven’t been able to afford my kids school books.’

That was not what I expected to hear, or anything they told me at medical school could result from examining a throat. That consultation took a very different direction, she was screened for other infections and was fortunately negative. We then talked about her dilemma and she decided there may be better ways to furnish her kids with what they needed for school.

There is very little evidence that the appearance of the throat aids the diagnosis in most cases- even a viral sore throat can mimic a bacterial infection. In any case in developed economies penicillin does not help the patients recover much quicker. However, anyone with a sore throat who consults a doctor expects to be examined. Besides why do people seek medical advice about pharyngitis? It is common knowledge that in most cases a couple of paracetamol, fluids and rest is the only effective treatment. In many cases people are expressing concern about some other aspect of their life when they present with minor self limiting illness. What people say, if you are receptive is

‘I’m unhappy, I’m worried, I’m bored, I’m feeling guilty, I’m tired or I’m not coping and this discomfort is the last straw.’

That’s one of the myriad of reasons that general practice is the most challenging medical specialty, nothing is necessarily what it seems at first glance.

Innovations don’t need to be high tech or expensive- a tongue depressor costs 13 cents. That doesn’t mean that in the right hands such simple equipment is not extraordinarily powerful. There are tools we seldom do without- a stethoscope is vital and not only because of what we can hear when we put it to the chest.

The secret to lean health innovation is harnessing the truth

In the later 1990s when I was practicing in a 7,000 patient practice in England we had a system of five minute appointments. Five minute appointments that were really ten minute appointments. In most cases a doctor can’t achieve anything useful during a five minute appointment. Some doctors would argue that ten or even fifteen minutes is scarcely enough. However this was how it had ‘always been done’ so the new doctors to the practice adopted the system that was in place. By the time you got to the last patient in every surgey you were running at least half an hour late. We were kidding ourselves—nobody ever finished by 11am. We were still consulting at midday and then rushing off to do home visits stuffing a sandwich in as we drove from patient to patient. We were back at the surgery by 2pm ready to start the whole thing again—intending to finish at 5, but in reality turning off the lights after everyone had gone at 6.30pm.

The data was right under our noses. Some doctors were known to ‘always run late’, others became adept at pushing patients in an out quickly with a prescription in their hand and instructions to return next week. Patients learned to choose the doctor they thought was best for them, whether that was one who would ‘get to the bottom of it’ or give you a prescription and a sick note but couldn’t be relied on to know when you had cancer.

Consulting style does impact a patient’s choice of doctor. and doctors and patients don’t always share the same view on their consultations.

Meanwhile back at the practice resentments festered because some doctors were having coffee in the staff room at 11 while their colleagues were still working through the list until nearly midday. There were suspicions that the early finishers were seeing fewer patients and never around when the emergency walk-in turned up at 11.45. Stressed doctors couldn’t see what was already evident to everyone else in the practice—we needed to redesign our appointment system and tackle issues engendered by our own delusions. In the end, as a practice, we needed to look at how each practitioner was consulting and how this was reflecting the practices’ values to its patients.

Something had to either change or give and we decided that if it wasn’t going to be us or the patients, then it had to be our system. We had to face the truth that the numbers of patient appointments we scheduled during the day was greater than our capacity to treat them properly in the time we allocated.

Our colleagues in other surgeries thought we were ‘brave’ to move to ten minute appointments. There were implications for radical changes to our appointment system. But the first thing we needed to recognise was that our schedule must treat our patients as if their time mattered at least as much as ours. It was, and is, unacceptable to keep patients waiting because we don’t want to accept reality. This denial leads to patients failing to keep their appointments, choosing to go elsewhere and it ultimately leads to doctors burning out.

We didn’t need a big R&D department to tell us what our staff and patients would say if we bothered to ask. I now work in Australia and still see the same patterns here. My friends tell me you can count on this doctor to prescribe antibiotics no matter what is wrong with you, and that one always gets to the bottom of things but prepare a packed lunch when you make an appointment with him.

Our time is not more important just because we are doctors. Innovation sometimes involves taking responsibility not investing in a new computer program or running a focus group.

Putting the patient first is not just good medicine, it’s good business

Primary healthcare is mostly organised as if all patients had the same needs. Patients who have a chronic illness who are repeat visitors and those with significant risk factors for future disease, are expected to fit into a system that is designed to meet the needs of someone with urgent and temporary illness. The current system is designed as if it doesn’t really matter which doctor consults them or what is known about their needs.

These are the facts:

1. Each week, there are 1,700 new cases of dementia in Australia; approx. one person every 6 minutes.

2. Cardiovascular disease affects one in six Australians

3. In 2011/12,4.6 million Australians(32%)aged 18years and over had high blood pressure (systolic or diastolic blood pressure is ≥140/90 mmHg or taking medication). Of these, more than two thirds (68%) had uncontrolled or unmanaged high blood pressure (not taking medication), representing 3.1 million adult Australians.

4. 1 in 2 Australian men and 1 in 3 Australian women will be diagnosed with cancer by the age of 85.

In some cases patients are expected to make appointments at a time and place that suits the practitioner. They might be seen for as little as 10 minutes and can feel that their questions and concerns have been addressed. The consequence is that both the doctor and the patient become frustrated.

The clinician complains about workload while the patient seeks alternative ways to meet their needs. There is published evidence that patients with chronic illnesses have significant unmet needs that impact on their quality of life.

The lean innovator knows that the future success of healthcare depends on serving the needs of those who are likely to need to consult a doctor many times in coming years. These patients need to live life despite pathology and to care for others even when they are not feeling their best. The person with enduring health problems also needs to believe that their doctor knows them, understands their perspective and has their best interests at heart.

In the business world such a loyal customer is prized. The business strives to make them feel valued. Great businesses constantly reinvent themselves and look for new ways to ensure that the customer is happy with the service on offer. It takes relatively little to satisfy the patient in a primary healthcare setting. We know, but sometimes forget, that what the patient craves most of all is their doctor’s undivided attention. Like a customer in any other business our patients want to feel that they matter.

We don’t need a department or a huge budget to innovate, because as both business owners and doctors we have the authority and insight to redesign how the patient feels from the moment they walk through the door and at every stage before and after their appointment.

If research has taught us anything it is that the fundamental need in healthcare is for their doctor to have good communication skills. Without that foundation nothing that technology can do for the patient will ever be good enough. Every touchpoint of the system needs to reflect the experience in the consulting room and should say to the patient—we know and care about you.

What is the most important thing you do for the people you serve? Do they get a sense of that from the moment they look for your help?

Why the future of health lies in thinking small

General Practice in Australia is a private business. There are 7200 GP businesses in Australia, with a revenue of $10bn per annum. Each practitioner is estimated to earn $200,000 on average. 95% of the income for these businesses is derived from government rebates, mostly from 10 to 15 minute consultations. The concerns of the practitioners in this context are said to be:

1. Threat of litigation

2. Too much work to do in a limited time

3. Earning enough money

4. Patients who are difficult to manage

5. Paperwork

6. Intrusion of work on family life

7. The cost of practice overheads

8. Time pressure to see patients

9. Unrealistic community expectations

10. Negative media comments

Increases in the Medicare rebate have failed to keep pace with the rise in the costs of running a GP service with increased patient throughput often used to make up the shortfall. Where this and other barriers exist, it may not be feasible for patients to be offered additional advice or services beyond their original reason for presentation unless a strategy is negotiated and agreed between the relevant players.

We know that the healthcare needs of patients are set to change in three important ways:

1. The population is aging.

2. There are more effective, albeit ever more expensive treatments available.

3. Poor lifestyle choices, linked to obesity will generate greater demand for medical appointments.

We are therefore relying on private businesses to respond to growing need in the knowledge that they are already working to capacity.

Under the central set of assumptions used in this study, total health and residential aged care expenditure is projected to increase by 189% in the period 2003 to 2033 from $85 billion to $246 billion—an increase of $161 billion….This is an increase from 9.3% of gross domestic product (GDP) in 2002–03 to 12.4% in 2032–33. Increases in volume of services per treated case are projected to account for half of this increase (50%). Projection of Australian health care expenditure by disease, 2003 to 2033

Another unique aspect of the business of medicine is that despite its technical and scientific basis, medicine is most effective when the human interaction between practitioner and patient is at its heart. Efforts to interfere in the process through the revision of payment schedules are only partially successful if not actually harmful.

The commercial reality is that without innovation, primary care as a business will not keep up with demand. To date evidence in practice is that researchers in primary care often fail to engage with clinical partners and innovation is stymied. Government investment in innovation in primary care is on the one hand conservative and limited. Ninety percent of government funded healthcare is delivered by small businesses and yet over 90% of government investment in research and innovation is targeted elsewhere. What little is funded is usually awarded to competing tertiary institutions whose performance is measured on academic outputs rather than impact on practice.

These are the foundations for a lean, agile, creative, approach to innovation  based on commercial reality and factoring in three key elements:

1. The most expensive component of innovation is establishing the problem and creating a value proposition that  factors in the perspective of end users.

2. Innovation only ever works when it is driven by a champion willing and able to re-engineer multiple prototypes to solve the problem.

3. There are opportunities for commercial partnerships if the key performance is reframed in the metrics of sales.

The conditions already exist for this approach to innovation in the business of primary care. Primary care in many countries, like Australia, is led by highly creative, intuitive problem solvers, many invest their insights and energy on small projects that have the scope for substantial commercial returns but more importantly to deal with the coming tsunami of health related problems. The final word is to Paul Graham:

People are bad at looking at seeds and guessing what size tree will grow out of them. The way you’ll get big ideas in, say, health care is by starting out with small ideas. If you try to do some big thing, you don’t just need it to be big; you need it to be good. And it’s really hard to do big and good simultaneously. So, what that means is you can either do something small and good and then gradually make it bigger, or do something big and bad and gradually make it better. And you know what? Empirically, starting big just does not work. That’s the way the government does things. They do something really big that’s really bad, and they think, Well, we’ll make it better, and then it never gets better.

The lean innovators’ insight

Simple access to medical records is a strategy for failure. Generate value to patients…people… then medical information and tools. Please do not reverse. Grant Taylor

When it comes to defining the value proposition lean innovators have a substantial advantage. They know that some innovations won’t work because:

1. They take up time that should be spent listening to the patient.

2. They require the practitioner to learn a new skill.

3. They are good for the patient but add an administrative load.

4. They assume the patient will invest time and effort on collecting information that has no apparent benefit to them.

5. They obviate the need for physical contact with the patient.

6.  They demand time and energy without solving any immediate problem.

Lean innovators- clinicians who practice their art-know this because they’ve been in the moment with those intended to benefit. They’ve sat opposite the person in crisis , the person who struggles to function or has to redesign their life and revise their dreams because of some all too inconvenient health problem. To that person it isn’t about the latest gadget or gizmo, they do not care if it helps the system to collect data. They want tangible benefit, they want human contact for which no device is a substitute and the lack of which reduces the potential for recovery and regeneration. For the practitioner an invention should fit seamlessly into their way of working and earning a living. The innovator knows that if an innovation is resented as an intrusion in practice, that end users will actively search for reasons that it ‘doesn’t fulfill its promise to patients’. Result: another promising idea shelved, another innovator frustrated.

Agile, Intuitive, Creative, Cost Effective Healthcare solutions