Welcome to NP Insights! This column is not a how-to or a didactic column, but one that encourages thought, curiosity, and reflection in regards to how NPs can make a difference in healthcare today.
With the advent of the meaningful use (MU) of electronic health records (EHRs), patient-centered medical homes (PCMHs), and accountable care organizations (ACOs), there are many standards of care and treatment guidelines that focus our patient care. During a patient visit, we are often keenly aware of the boxes that must be checked to comply. EHRs have not only made it easier to capture required data, in many cases, they are designed around these guidelines to facilitate data collection. As a result, the patient visit can become a process of getting what we as clinicians and our healthcare organizations need for PCMHs, MU, or ACOs. Several years ago, a former student of mine shared her frustration as she was growing in her new nurse practitioner (NP) role saying, “We spend so much time focusing on artificial markers of healthcare that insurance companies (and now PCMHs and ACOs) require for HMO reimbursement, that we do not focus on the real markers of health.”
There are research papers stating that we are only giving 50% of “recommended care,” implying that we are not providing optimal care.1 What do these studies measure? Are we meeting 100% of the recommended guidelines? If not, for example, if a person with diabetes does not have a foot check at one visit, is that substandard care? What if the time was spent counseling the patient's depression due to a traumatic event or on lifestyle changes which, at the next visit, resulted in significant weight loss? These things may have been more important than a foot check.
The Institute of Medicine Report, Crossing the Quality Chasm: A New Health System for the 21st Century, stresses the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.2 However, patient-centered care seems to be evaluated by the data it creates. We now receive regular quality reports that show how adherent we have been to the guidelines. Have the checked boxes or clinical guidelines become the focus of our patient visits?
What happened to patient choice in these guidelines? Are these guidelines taking into account individual patient preferences, needs, and values? Are we explaining the benefits and risks of these guidelines to ensure that patient values guide all clinical decisions?
A tale of two patients: quality measures
55-year-old female patient #1 with diabetes
* HbA1c is 6.8%, increased from the last HbA1c level of 6.4%. The patient is taking three oral diabetes agents and basal insulin.
* BP is at goal (118/80), and the patient is taking three antihypertensive medications.
* LDL-C level is 98 mg/dL, and the patient is taking simvastatin 40 mg daily in the evening.
* The patient is a smoker and was given a prescription for varenicline.
* A screening colonoscopy was ordered.
* A screening mammogram was ordered.
* Body mass index (BMI) is 43, an increase from 39 a year ago.
55-year-old female patient #2 with diabetes
* HbA1c is 7.4%, decreased from the last HbA1c level of 8.1%. The patient is not on any medications for diabetes.
* BP is 142/86, decreased from the last reading of 160/100 with lifestyle changes alone. The patient is not on any antihypertensive medications.
* LDL-C level is 108 mg/dL without medications and is down from 157 mg/dL after a 35 lb (15.9 kg) weight loss over 2 years.
* The patient quit smoking 2 weeks ago “cold turkey.”
* Discussed colon cancer screening risks, benefits, and options. The patient declined screening, has no family history of colon cancer, and is exercising, losing weight, and plans to eat more fruits and vegetables to reduce colon cancer risk.
* The patient has no family history of breast cancer, has been making healthier lifestyle choices, and is concerned about false positive results with mammography. She would like to try to lower her risk for breast cancer by getting more exercise and declines a mammogram.
* BMI is 33, down from 40 a year ago.
Which patient is doing better? Which is receiving better, value-driven care? Patient #1 met all of the quality measures by taking nine medications, yet her weight and HbA1c are getting worse. Patient #2 met a few of the quality measures, yet is on no medications, and has made significant improvements with lifestyle changes alone. Sometimes I want to say, “The emperor is wearing no clothes!”
The concepts of MUs, PCMHs, and ACOs are wonderful in theory, but are we really measuring the kind of things that will show better health and better healthcare?
Maximizing value for patients
Michael Porter states, “We need to measure true health outcomes rather than relying solely on process measures, such as compliance with practice guidelines, which are incomplete and slow to change.”3 Porter goes on to say that the core strategy to fix our healthcare system is maximizing value for patients (health outcomes per dollar spent).3
Besides “grading” us, how do the current quality reports help us to grow or improve, and more importantly, how well do they indicate value for patients? Adherence to guidelines is a process measure. The reports do not tell us if the patient had other needs that superseded the practice guidelines on that particular visit. The reports do not give a context to what was going on with the patient, they are simply a summary evaluation of the clinician without regard to patient needs or clinical outcomes. We have to ask if this kind of care is really patient-centered, outcome-oriented, and whether or not it improves healthcare.
Patient-centered care is not one size fits all. It looks at the patient, the risk factors, past history, family history, social history, and stratifies risk based on these. Patient-focused care looks at what the patient needs on any particular day. It does not begin with a laundry list of things that the provider needs completed. That list (the list of data to capture) is provider- and data centered–not patient driven. It is not that these guidelines and standards should be ignored, as they are an excellent framework, a piece of the puzzle, and a starting point to share so that the patient can make informed choices; however, all too often, they become the goal of the visit.
Delivering high-value care
How do we reconcile all of this in giving patient-centered, value-driven care? First, we should try to work together to adapt our PCMHs to high-value care. For example, instead of diabetes and hypertension as two of the three chronic diseases an NP plans to follow, consider following obesity and tobacco addiction instead. Maybe the EHR can be set to track weight loss, counseling parameters, or even changes in HbA1c and BP rather than end points or goals. Perhaps the process of shared decision making, of sharing the risks and benefits with the patient, could be documented along with documentation if a patient declines to follow the guideline. In addition, as high-value care is given, many of the parameters that are being monitored for PCMH, MU, and ACOs (BP, LDL-C, HbA1c) will likely improve as a result—they are the outcome rather than the process. Finally, ACOs will be collecting data on expenses and on some long-term outcomes along with measuring the processes. If we strive to give patient-centered, high-value care, even if all of the other processes are not met, we will be able to use cost and outcome data over time to show that giving patients choices is a more effective way to give high-value care.
Eye on the goal
It is important to keep our eyes on the goal. Our goal should always be excellent, patient-centered, high-value care. We want to see patient satisfaction and patient involvement in decisions with improved outcomes, not simply processes. The primary goal should be high-value care, not meeting criteria for meaningful use, ACO, or PCMH. As Porter says, “We must move away from a supply-driven healthcare system organized around what physicians do and towards a patient-centered system organized around what patients need.”4 Clinical guidelines are useful, evolving tools. Data are often averages and syntheses of information that do not give a clear picture of an individual patient. We need to remember to focus on giving high-value, patient-centered care. Data can help us get there, but we must not let it distract us from the patients' needs, goals, values, and care. We must not only ask our patients what is the matter with them, we must also ask what matters to them most.