In a new book published in 2016 in the U.K. “Using Patient Reported Outcomes to Improve Health Care”, the authors,  Appleby, Devlin and Parkin, demonstrate how in multiple ways PROMs can improve healthcare.

In Australia there is also movement with the Victorian DHHS starting to collect PROMs from 01/07/2017.

PROMs are also probably the most effective tool to help overcome long term issues:

• To reduce hospital adverse events and achieve the largest improvement in the Health and Safety and Quality Patient Care.
• In the GP environment for the first time to integrate Primary Health Clinical Care and Public Health.
• In medicine, they are the agency to move from the Newtonian medicine to Einsteinian medicine.

In this way medicine will incorporate the great advances of physics in the last 100 years, to be really medicine based on modern science.

In an interesting development, the Competition and Markets Authority (CMA) in the UK has regulated that from April 2017 all private hospitals must collect and report  data collected by PROMs in 11 procedures. This reporting will be done through the Private Health Information Network (PHIN) and thus publicly available.

The PHIN foreshadows an additional 13 disease/body part specific PROMs to be collected within 12 months.

eHealthier applauds this development and notes that the UK and NHS are the first health system to measure health rather than only measuring healthcare.

The PHIN has some excellent insights to PROMs and their potential.

Paper “eHealthier and Social Impact Bond”

2. Aligning accountability with responsibility

Wellness (“Wellbeing”) Programmes offered by employers would be better provided by Primary Care Physicians. Good management practice aligns responsibility with accountability.

Employer-run wellness programmes make the management mistake of separating responsibility from accountability.

Should an employee develop a non-work related illness, e.g. “kidney disease”, is the employer accountable?

Physicians are being held accountable for prevention for which they have no responsibility.  Giving physicians the capacity to measure the preventive ePROMs and take corrective action, aligns responsibility with accountability.

Currently the cost of healthcare in Australia is $155 billion per year and wellness programmes are run by employers.

I should not be the only kid on the block who points out that this makes no sense, the emperor has no clothes.

Those providing healthcare are not providing the “health” part of healthcare

Western Health Systems Management Errors.

There are a number of fundamental management theory mistakes, that continue today that have led to under-performance and continue to do so that I will highlight in the next few blogs.

1 Failure to define and then measure the correct objectives of the healthcare system.

There have always been 4 objectives,goals or aims and these are: prolonging life, restoring function,relieving distress and preventing disease and disability.Only prolonging life has been measured by life expectancies.The other 3 objectives can now not only be measured but can be measured in individual patients with minimal patient burden by utilising ePROMs,as set out in the eHealthier website.These are known as Functional ePROMs, Cared-For ePROMs,and Preventive ePROMs.Until these are used in daily clinical,hospital and population management practice,western health systems will continue to underperform

 

 

Further to my previous blog post (see New Item Numbers in Medicare could help Save Billions!) as far as achieving the desired aims of both the Primary Health Care Advisory Group and Medicare Benefits Schedule Review Taskforce, I would recommend the following new or adjusted item numbers.

• Preventing PPHA (Potentially Preventable Hospital Admissions) as set out in my previous blog post
• Preventive ePROMs for Population Health Management by GPs – under this item number  General Practitioners collect via ePROMs each individual’s Body Mass Index and key Behavioural risk factors (smoking, alcohol consumption and fruit and vegetable consumption along with their physical activity data) and thereby accumulate annually their total GP population profile such as percentage smokers, percentage excess alcohol consumption, percentage obese etc. The GP then prescribes ‘lifescripts’ health apps with the aim to achieve a small percentage improvement in her or his population profile for the coming year. You can find the full ePROM here 
• Chronic Disease Management Item Numbers – these item number requirements be altered to include the use of  at least one generic and one disease specific ePROMs that requires the GP to set an ePROM quantified goal for  the sufferer of that specific chronic disease and leads to the prescription of an ePROM treatment or health app, in addition to the team care arrangement.

The Healthier Medicare Review of the MBS  schedule of fees offers a unique opportunity to indeed create a healthier Medicare by the inclusion of  Patient Reported Outcomes as a requirement for a variety of Primary Care as well as specialist surgical procedure item numbers.

Relevant item numbers would include those for operations on the prostate, cardiovascular, for cardiac surgery procedures and orthopaedics for a variety of spine, shoulder, elbow, wrist, hip and knee operations. We would recommend utilising the PROMs set out in ICHOM Standard Sets or those recommended by the American Association of Orthopaedic Surgeons.

By recording the PROM scores from: prior the operative intervention, immediately at discharge and at 3 month intervals or as set out by ICHOM in their follow up protocols.

Surgeons will be able to demonstrate the improvement achieved or otherwise in their patients functional health or the patients’ continuing health related Quality of Life in response to the surgical intervention.

In Primary Care an item number utilising a generic PROM such as the SF12 together with PROMs that measure risk factors such as smoking , alcohol consumption, vegetable daily intake, fruit consumption and physical exercise would enable GPs to have a predictive individual score for potential hospitalization within 6 months. This will enable them to prescribe lifestyle changes and non-hospitalization outpatient care such as social work, dietician, exercise physiologist etc. interventions that will help avoid the known 6.2% of potentially avoidable hospital admissions that have been monitored and stayed static over the last 7 years.

One aim of this initiative, for example, would be to identify and reduce potentially avoidable hospital admissions from 6.2% to 2.6% of all admissions (a 58% reduction). This would result in a saving in excess of $2 billion per annum in the current health budget. The calculation of this saving is as follows.

Australian figures reveal 10.5 million hospital admissions per year (see http://www.aihw.gov.au/publication-detail/?id=60129551440 ) and the Australian Bureau of Statistics reveals that 11.8% of the Australian population are admitted each year (that is 2.6 million persons) . Some patients (usually dialysis patients) have more than 4 admissions per year. see http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/D6EC4DD7DC21B01DCA257B39000F2D00?opendocument )

Assuming 1 000 patient equivalents per GP on average each GP would have 118 of their patient population admitted to hospital per year. If each GP managed to reduce just 15 overnight hospital admissions per year by implementing the lifestyle and preventive prescriptions, then, at the current  cost of approximately $6 000 per admission, each GP could save the health budget $90 000 per year. Assuming all 24 000 FTE GPs adopt the changes, a total saving of approximately A$2.2 billion would ensue.

The above graphic displays the predictive capacity for the hospitalisation of an individual from their PCS score in SF12 PROM. The GP would be encouraged to set a goal to improve that patient’s score by 5 units such that the patient would move from their initial band (e.g. 35-40) to the next band (say 40-45 in the above graphic), thus, in aggregate, reducing the likelihood of hospitalisation of their total pool of patients.

There is ample evidence that preventive strategies have a higher probability of adoption where the patient is guided by their GP’s lifestyle prescription provided they are monitored monthly by completion of the ePROM and are provided with 4 well constructed reminders per week. (see http://jama.jamanetwork.com/article.aspx?articleid=2442937 )

Australia’s current Federal Health Minister, Sussan Ley, has embarked on a review of Medicare particularly the Medical Benefits Schedule (MBS) and complex and chronic conditions in Primary Health Care known as the Healthier Medicare Initiative. This is an exciting development in the move to the broader adoption of Outcomes based medicine in Australia, with its promise of better health outcomes while making Medicare more sustainable.

As eHealthier  shares the goal of a healthier Australia we believe that the introduction of a Medicare item that incentivises Primary Care Physicians to utilise ePROMs as part of their Care Plans and in particular includes newer ePROMs such as probability of repeated hospital readmissions measures. This would be a first step to reaching this goal.

Should Australia decide to include the next generation of personal ePROMs i.e. Preventive (risk factor) and “Cared-For” ePROMs in the MBS item numbers not only will Medicare be financially healthier it will result in a healthier Australian population.

With the ubiquity of ‘smart’ mobile and wearable devices that measure a person’s functioning over time and are usually within an arm’s length of the owner, the possibility of monitoring patients utilising either these wearable devices or in the first instance allowing them access any time any where to complete shortform questionnaires, health outcomes are now more commonly known as PROMs (please see both of the following Wikipedia entries https://en.wikipedia.org/wiki/Routine_health_outcomes_measurement and https://en.wikipedia.org/wiki/Patient-reported_outcome). In particular, at the bottom of the second article has a link to another entry on electronic Patient Reported Outcomes.

The demographic and financial paths before the Western developed world are proving to be catalysts to address what were once considered intractable problems with delivery of widespread quality health care. Finally focus is moving towards the outcomes of medical care as a means for evaluating the success (or otherwise) of interventions. However to measure outcomes, we need to establish a baseline prior to treatment and then establish a transparent and reliable measure of the treatment’s impact on the life of the recipient – the patient. Patient centred outcome measures are emerging as a potentially powerful tool to direct and improve medical decisions with outsized cost reductions at the same time.

As the media comes across such stories, we at eHealthier will post the links and associated commentary on our blog page for interested parties to follow up.

Looking through a publication from Yale by the Center for Outcomes Research & Evaluation (CORE), I came across the following.

Top Medical Experts: How to Fix Health Care

This first article gives the opinions of 11 medical experts in America on how to fix the health system. Interesting that most see the use of patient data and even a reversal of the roles of doctor patient, as crucial for improving health outcomes. Three of the opinions are copied below.

 Improve transparency

When consumers choose health care, they have precious little information on the outcomes that are meaningful for them. How long will I be out of work? How well is my pain controlled? How likely am I to get an infection if I have this procedure done by this doctor? If consumers had as much information about health care as they do about consumer products, we would see dramatic improvements in quality — and reduced costs. If consumers and employers and insurers had access to this data, perhaps then we would begin to reduce the disparities and the variation in quality of care among health care organizations. When you buy an airline ticket, do you ever think of checking to see how safe the airline is? No, safety is guaranteed. The airline industry has institutionalized safe practices so all the airlines are safe. You choose your ticket on price, or on service. That’s where we need to go with health care. Part of that is being transparent about where we are doing well and where we are falling short.”

Empower patients

We talk about patient-centered care, but we really have doctor-centered care. What I want are tools that patients can use to empower themselves. Right now I’m the doctor. I have all the knowledge. I’m in control. I want to flip that dynamic. In the same way I am required by law to ask about allergies and medications, and talk about a past medical history, I want doctors to take the time to sit down, slow down and ask a patient: What’s a good day for them? What’s important for them? What are their values? What are their religious beliefs, their ritual beliefs? I want to know what their hopes and fears are for medical care, and where they want to spend the end of their life. I want to be required to have to ask that of all patients, at least to give them the opportunity. And sure, there may be some patients who are not ready to have that conversation, but I want them to know that I am open to having that conversation. It’s the ultimate wellness pitch, I tell people: We are all going to die someday, and part of living well means addressing this life’s final chapter. That’s not about end of life. It’s about a good life, for as long as you can, as best as you can.”

Put health data to work

The real change that needs to happen is one that puts patients in control of their data. Hospitals are monetizing your data all the time. Hospitals hold data and allow people to look or copy, but it is not always easy to bring together all the information. You should have control over your data and have the ability to share it securely with anyone you want. This will shift the balance of power toward the patient, allowing people to do comparative shopping for their health care, and reducing costs, because today it’s easier to repeat tests than get the data from another doctor or hospital. Sometimes bad things happen because critical information isn’t available; sometimes it’s because people are getting care at different places and the information never comes together in one place. There are personal health records out there, but they require the patient to do a lot of work. We need to get to a system where patients have access to their own data that they can use seamlessly. Ideally, it would be like your bank account. You can easily access all of your financial information online. Why not your health records?