Even with excellent evidence-based practice guidelines and the best HIT tools, the Quality though Knowledge model will fail unless healthcare providers are willing to implement the guidelines and use the tools in QI programs that benefit the consumer. While provider motivation is increasing, there are still daunting challenges, but there are also realistic solutions.

Problem: Poor Financial Compensation to Providers

Providers are in a paradoxical situation: The current healthcare system is designed to reward providers for rendering inefficient, sub-optimal care, while their professional ethics and compassion for their patients pushes them to deliver high-quality care. This dilemma is due, in part, to reimbursement practices that reduce providers' remuneration while encouraging them to spend less time with their patients, discharge them quickly, and treatment them again when problems re-occur. At the same time, the threat of malpractice suits pressure providers to overtest, overtreat, and overrefer their patients. These pressures to overtreat, however, do not cancel out the reimbursement incentives to undertreat. The result is less effective clinical practice and enormous amounts of paperwork that drain providers' time and resources. It is all very demoralizing to providers and points to the need for a change in reimbursement strategies and response to malpractice threats.

Reasons for this financial Problem include:
  • A fragmented health system - in which the patient moves among different providers, employers, and payers - causes the financial incentives for improving care quality to be misaligned because those paying for the care and delivering that care become disconnected over time.
  • A payment system (administrative pricing) that mainly reflects resource costs, not benefits to the patient, so ordinary, even defective care receives the same payment as optimal care.
  • The financial benefits of improved patient outcomes and reduced cost occur mainly in the long term, thereby giving insufficient short-term incentive to pay for high-quality care, especially for chronic illnesses. For example, insurance pays more to treat diabetes complications than to support programs helping patients control the disease. Many insurers, for example, do not pay $150 for a diabetic to see a podiatrist for prevention of foot ailments, but they pay more than $30,000 for amputations, a common complication of the disease. And patients have receiving reimbursement for a $75 visit to the nutritionist for counseling in controlling diabetes, but they will pay $315 for a single session of dialysis to treat one of its complications.[1]

Solution: Use Effective Financial Incentives

Despite their problems cited earlier, financial incentives such as pay for performance (P4P) strongly encourage providers to focus on quality improvement.[2,3,4] Coupling such incentives with other solutions can overcome their current limitations and be useful motivators.

P4P is gaining momentum. For example, the American Medical Association has just signed a pact with Congress promising to develop more than 100 standard performance measures doctors will report to the federal government as part of P4P arrangement in response to purchasers' and consumers' demand for more information on the quality of care. The performance measures will be process outcome metrics focusing on diagnostic tests and treatments known to produce better patient outcomes. While some physicians fear this is just a smoke screen to cut costs and reduce healthcare resources, others are say they have to be involved or there would be dozens of disparate measures foisted on them by payers and other outside organizations. Yet the timetable may be unrealistic because performance measures need adequate time to be tested and validated.[5]

Any appropriate policy responding to providers' income concerns should ensure that fees reflect the true cost and value of the services performed, as well as align financial, quality-of-care, and operational incentives. It should not, however, sanction business models that perpetuates conflict of interest, increase utilization, nor weakens community hospitals.[6]

Problem: Unsupportive Organizational Culture and Lack of Leadership

Healthcare organizations not focused on learning and who lack the leadership to drive QI initiatives are unlikely to implement practice guidelines and are not prepared to succeed in the changing healthcare environment. Such stagnant organizational cultures cannot evolve and will be unable to compete in a world focusing on quality improvement.

The lack of leadership is also a result of fear that taking a hard stand on quality improvement could lead to loss of income/revenue. And since the average consumer and provider are largely unaware that there is a quality crisis in American healthcare, there is even less incentive to push a quality agenda.[7]

Solution: Focus on Learning Organizations with Leadership for Change and Increasing Public Awareness

Organizations with leaders focused on learning and improving have the organizational culture necessary for implementing creative and effective solutions in healthcare delivery.[8] Strong support of senior management in an organization and effective clinical leadership speeds adoption of innovative technologies and care processes. These agile organizations are dedicated to providing the best possible care and will gain increasing competitive advantage as the healthcare system evolves. Those taking the initiative now will be better prepared to thrive in the near future.

In addition, more must be done to increase people's awareness that the quality of healthcare is our country is in crisis.

Problem: Unwillingness to Change, Lack of Self-Confidence, Skepticism, and Insufficient Time and Resources

Provider qualities, characteristics, and resources play an important role in their willingness to implement evidence-based practice guidelines and HIT in QI program. Problems occur when providers:
  • Are not willing to change the way they have done things in the past because they are set in their ways
  • Lack confidence that they will be able to do what the guidelines recommend and use the HIT tools effectively
  • Don't believe the guidelines or tools will be effective because they are not valid, cost-effective, practical, or applicable to their particular patients
  • Encounter external problems, such as time limitations and lack of resources.

Solution: Support by Clinician Champions

Clinician champions are typically well-respected practitioners who have an interest in innovative technologies and ideas and can influence others. They are sometimes referred to as early adopters, opinion leaders, change agents, catalysts, or gatekeepers. Having such an individual speak to colleagues about the benefits of an HIT tool, evidence-based practice guidelines, and QI (Quality Improvement) programs can increase others' willingness to change and try new things. Champions are also valuable in relaying the concerns and frustrations of other providers.

Solution: Increase Clinician Confidence

Clinicians' confidence and ability to render the care prescribed in a practice guideline depends on several things, including their prior training and level of skill, as well as the value of the instructional materials and educational support that comes with the guidelines. It is therefore imperative that guidelines enable practitioners to render the prescribed care competently through continued education and training.

Solution: Gradual Implementation with Ample Support and Workflow Accommodation

Clinicians who are uncomfortable with change typically find it easier to continue their "tried and true" treatment methods despite valid evidence that alternatives are likely to result in better outcomes. Since the integration of guidelines and tools in clinical practice is an evolving process, introducing them can be done in a gradual and supportive way to help clinicians prepare for implementation. Multiple strategies can be used to facilitate implementation, including educational outreach, academic detailing, use of reminders, and other interventions based on assessments of potential barriers to change.[9,10]

In addition, the any HIT tools should be customized to operate seamlessly in providers' everyday workflows. This helps save time and reduces frustration, which speeds acceptance and adoption.

Solution: Have Adequate Time and Resources

It is possible that certain providers will find certain guidelines demand greater time and resources (e.g., equipment, staff, and materials) than procedures and methods they currently use. If these guidelines require time and resources beyond their capabilities, they will not be able to comply with the recommendations. It is therefore imperative that as guidelines and HIT tools are developed, there is due consideration given to demands for provider time and resources, and such demands should be as little as possible to achieve the desired outcomes.

Enabling providers to have the time and resources they need is consistent with the high-fidelity healthcare system discussed earlier.

Solution: Recognize Competitive Value

Providers who are open-minded, flexible, and willing to make changes to increase their competitive advantage will be the ones who thrive long-term. In today's rapidly changing world, the more "agile" practitioners and organizations are the ones more likely to succeed. Recognizing this competitive value diminishes provider resistance.

Gaining Competitive Advantage Using a Socially Responsible Business Model

From a "socially responsible investment" model perspective, making business decisions and using strategies that have a beneficial affect on society, such as care quality improvement, makes good economic sense because there is strong evidence from numerous studies that this model ultimately results in better financial returns and outperforms competitors.[11] In fact, the Domini 400 Social Index (DSI 400) - the gold standard of socially responsible funds - has outperformed the S&P 500 on a total return and risk-adjusted basis every year since its inception 15 years ago.[12]

Gaining Competitive Advantage via Value-Based Competition on Results

As discussed earlier, value-based competition on results focuses on gaining referrals and income by forming clinical practice units that integrate the talent and facilities necessary to deliver coordinated care for every care cycle. The teams demonstrate their ability to deliver high quality, cost-effective care through experience, expertise, and efficiencies gained by treating particular conditions only.

Blog links - Social Responsibility:
ยป Socially responsible ways to transform healthcare and the challenges

Next: Problem of Consumer Ignorance when Selecting Providers and How to Solve It

Footnotes and References

[1] Urbina, A. (January 11, 2006) In the Treatment of Diabetes, Success Often Does Not Pay. NY Times.
[2] Goldfield, N., Burford, R., Averill, R., Boissonnault, B., Kelly, W., Kravis, T., et al. (2005). Pay for performance: An excellent idea that simply needs implementation. Quality Management in Health Care, 14(1), 31-44.
[3] Shojania, K. G., & Grimshaw, J. M. (2005). Evidence-based quality improvement: The state of the science. Health Affairs, 24(1), 138-150. Available at http://content.healthaffairs.org/cgi/content/abstract/24/1/138
[4] Roland, M. O. (2004). Linking physicians pay to the quality of care-A major experiment in the United Kingdom. The New England Journal of Medicine, 351(14), 1448-1454.
[5] Pear, R. (February 21, 2006). A.M.A. to Develop Measure of Quality of Medical Care. New York Times. Available at http://www.nytimes.com/2006/02/21/politics/21docs.html
[6] Kahn, C.N. (2006) Intolerable Risk, Irreparable Harm: The Legacy Of Physician-Owned Specialty Hospitals. Health Affairs; 25(1), 130-133. Available at http://content.healthaffairs.org/cgi/content/abstract/25/1/130
[7] Millenson, M.L. (2006) What Will It Take to Move Towards a 'Prius' in Health Care? Presentation at the 13th Princeton Conference Counsel on Health Care Economics and Policy. Available at http://council.brandeis.edu/pubs/Prince13/Princeton%20Millenson_Prius.pdf
[8] Carroll, J. S., & Edmondson, A. C. (2002). Leading organizational learning in health care. Quality and Safety in Health Care, 11, 51-56.
[9] Grimshaw, J. M., Shirran, L., Thomas, R., Mowatt, G., Fraser, C., Bero, L., et al. (2001). Changing provider behavior: an overview of systematic reviews of interventions. Medical Care, 39(8 Suppl 2), II2-45.
[10] Grimshaw, J. M., Thomas, R. E., MacLennan, G., Fraser, C., Ramsay, C. R., Vale, L., everything al. (2004). Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment, 8(6).
[11] Kelly, M. (Winter 2005). Holy Grail Found: Absolute, definitive proof that responsible companies perform better financially. Business Ethics Online. Available at http://www.business-ethics.com/current_issue/winter_2005_holy_grail_article.html
[12] Orlitzky, M. et al. Corporate Social and Financial Performance: A Meta Analysis (2004). Social Investment Forum Foundation. Available at http://www.socialinvest.org/areas/research/Moskowitz/2004MoskowitSummary.pdf

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