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Apr
20
2006

Kohler_1 Welcome to the health care reform blog. I look forward to sharing ideas and “blogging” with you about health care reform.

I have been privileged to serve as OHSU’s president since 1988 and, during this time, I’ve witnessed huge leaps in medicine. However, extraordinary medical breakthroughs and technology advances lose some of their luster when so many people can’t afford them. As you know, health care for many people is a serious economic challenge. In Oregon alone, over 600,000 people are uninsured. Hundreds of thousands of others are underinsured.

This is an unacceptable situation. I think we can all agree that everyone deserves access to basic health care. The question is: how do we as a society come together to create a health care system to achieve this? The answer to this question is not clear and the problems our current health care system faces are huge. But we must begin the process of change despite how daunting the task.

I hope that the debate and discussion on this site will be one way we can all help generate momentum for solutions to our health care access crisis. In this spirit, I’ll present a concept I’ve been thinking about for awhile. The idea is still in the conceptual stage but that’s what this blog is all about – sharing ideas, discussing solutions, debating alternatives – and I look forward to your comments.

As a prelude, consider the editorial below written by Mike Thoele, publisher of the Junction City Tri-County News. He kindly gave me permission to borrow the lighthearted touch he brought to my idea when he wrote about it in February.

Rx: the computer is in
So you’re feeling poorly? It may be time to make an appointment with the computer.

Don’t laugh. You could be one of 5,000 Oregonians asked to do just that in an experiment proposed by Dr. Peter Kohler, president of Oregon Health & Science University, the state’s medical school. You – and your wallet – might even wind up liking Kohler’s idea.

The good doctor’s experimental concept is no panacea – just an idea that might make some incremental difference in getting health care to unserved and underserved Oregonians. His proposal is to handle initial or routine patient encounters with medical assistants, assisted by some very sophisticated computer software based on medical protocols and backed by a team of nurses and doctors.

Kohler’s looking for funding for the experiment. If he lands it, he would offer the service to 5,000 individuals who have lost coverage under the Oregon Health Plan over the past three years. Kohler’s hypothesis is that this non-traditional approach – which would be run as a clinical trial – could lower costs and could even provide better results, because it would offer a level of preventive care not generally available to low-income patients.

The whole answer? Certainly not. An intriguing new piece for the health care puzzle? It could well be. Let’s hope that Kohler finds the financing for his proposed experiment. MT  ###

In the proposed study that Mike just described, I envision that a patient would first see a Medical Assistant (MA) for routine services while nurses, physicians assistants and physicians (or other specialists) – all of whom cost more – would be used for more complex situations. The MA would rely on advanced information technology (IT) applications, including decision supporting computer software that would allow many health care decisions to be made without ever seeing a physician.

Consider: you don’t always need a physician to tell you to rest and drink lots of fluids when you get the flu. A sore throat may not require a physician’s or nurse’s attention. A physicians assistant can usually stitch up a child’s simple cut. Decision supporting software can aid MAs and other providers in these common situations along with reminding and educating patients about important preventive health actions, like mammograms or inoculations.

I agree with Mike that this is not THE answer to all of our health care challenges, but it could potentially result in a more rational use of health care expertise (and dollars) by allowing physicians and specialists to spend more time with the patients who really need them. This would also decrease the need for future physicians, thus helping to offset expected work force shortages.

If we shift the emphasis from physicians to health care teams, we may be able to both reduce costs and improve health. The cost savings could be redirected to help in the related goal of expanding access to everyone.

Many people have done a great deal of thinking and work on this concept, and I don’t take credit for the original idea. I am an experimentalist at heart, however, and I’d like to see this idea transformed into an actual study. With the help of OHSU’s Public Health and Preventive Medicine Department, I’m working on a study design, including ways to measure success.

That’s it for my initial entry in this blog. I look forward to the discussion that follows. What would be the value of this undertaking? Philosophically, does this seem like a good idea? What are options for getting a large-scale test off the ground? Let’s blog it.

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Join the dialogue here

Apr 20, 2006 10:25:09 PM
L.S. Brown says

Dr. Kohler,

I would first like to congratulate you on a great tenure here at OHSU! Your true dedication the betterment and advancement of medicine as well as your dedication to working with the community. Your efforts in building a lasting relationship for those future generations of community members and OHSU patrons and employees will surely be enjoyed well into the futre. Big ideas require strength and perseverance, both admirably displayed in many of your endeavors.

Your conception of patient and healthcare professionals interfacing with each other via computers is a great example of taking the next step. OHSU’s ranking in the top 100 of the nations healthcare institutions is sure to get a boost with the inception and implementation of such a program.

Already I can see the great benefits of such a system in my current occupation as a clinical research coordinator at OHSU’s Center for Hematologic Malignancies. Our clinical research department has study subjects throughout the state of Oregon and America. The benefits for a cancer patient to be able to interface with a clinician whether it is their doctor, a nurse practitioner or a coordinator is overwhelming in many regards. Decreased travel for the patient to name one benefit, but more importantly the event that it creates a palatable and tangible means of contact at times when it is crucial to make contact for both sides.

The concept of computer interface tackles real problems that at a glance seem minor but in culmination with the greater picture can be quite daunting for all parties. What is now done with phones and e-mail can be expounded on in innumerable ways. But the greatest is the humanization of that contact. Rather than bothersome phone tag or e-mailing back and forth, a team of people can connect at one set time, as any doctor’s appointment is done now, and cut the effort in half.

While there are some minor logistical issues that are created (i.e. billing, scheduling, access to computers for people who are living at poverty levels), they are minor in comparison to the solutions that will evolve from such a system. The far reaching benefits will out weigh the drawbacks once in place and fully in effect.

It is things like this that make me proud to be a part of the OHSU community, and to work in an environment where daring to try harder at something new is encouraged. Challenges are like mountains you can always find away to traverse them. And to those who ask “At what price though?” I say, shame on you for pricing humanity. Quantifying that which can not always be understood, breeds doubt and doubt has never seen the summit, even that of an ant hill.

Thank-you, again for you leadership and vision Dr. Kohler, may your boots always find the path to the top.

L.S. Brown


P.S. I would like to also say thank-you to the pepole behind the scenes that put such a great effort into this endevor.

Apr 21, 2006 11:36:09 AM
Tess Yevka says

Dr. Kohler,

Cool idea. Personally, I find it very disturbing to have a simple issue and then find I'm paying a physician a large fee to take care of something a nurse or medical assistant could have treated. Also, it might free up physicians to give better and more personal care to those patients who need more intensive treatment.

I would certainly take advantage of such a system.

What if the Oregon Health Plan moved to that model? Might it be able to put a few of the "dopped" people back into the ranks of those with health care?

Send me to Laptop RX.

Apr 21, 2006 4:19:39 PM
Ted Amann says

Great idea. Our traditional healthcare "system" has become much too physician-centric and enthralled with the more lucrative areas of sub-specialties and high-tech interventions, rather than focusing on the high-volume (but less profitable) issues of everyday health and wellness. Using the full range of healthcare professionals - and we are fortunate in Oregon to have so many practitioners of the healing arts available to us - and adding para-professionals, like "healthcare guides" and "peer mentors", will not only be more cost effective but also more patient centered, efficient, and equitable. (4 out of the 6 Aims from the IOM's Qualiry Chasm!)

May 2, 2006 9:12:07 AM
Myra P. says

Maybe your idea could be expanded to include (or test?) the issue of health versus health care. More and more people are talking about moving away from health care as a commodity/industry to a broader concept of health in general. In your study, could you include a third group who get other services to improve or enhance their lives in ways that indirectly support health? Things like nutrition counseling, financial counseling, environmental health knowledge, etc. This could even be done to some extent through software too. Tough to design but moving away from health care as an industry and placing it in a continuum of "health" seems worth the effort?

May 3, 2006 2:02:24 PM
tjnorris says

I must say that this voice for the people is a long time in the making, and is well worth the breadth and effort that went into it. A continuous dialogue about the changes in the healthcare system where all have ready access to services is an oft precluded topicboth politically and from a business model. It's great to see a pro-active stance of these critical cracks in our foundation. Thanks for your expertise and voice.

May 4, 2006 5:31:10 PM
Peter Kohler says

Thanks for all the comments. I remain quite enthusiastic about this trial. I should emphasize that health is the goal for the study group. We anticipate building health promoting activities and prevention into the programs so that specific results can be part of the "outcomes" measured. I will check with the staticians about whether a third group is needed.

Peter Kohler

May 5, 2006 12:46:21 PM
OHSU Employee says

First off, I want to commend Dr. Kohler for his years of service to OHSU. We will miss your expertise. This trial is an excellent experiment and very much appreciated.

I am a current employee of OHSU and would like to remain anonymous because I'm embarrassed to say that I am not under-insured but rather cannot afford to pay the large deductibles. In addition to covering the additional premium that is not covered by OHSU benefit dollars, is the out of pocket expenses. If my spouse, I and just one child used our medical insurance, I’m looking at a $750.00 before insurance picks up 80% of anything above the annual deductible. I've been forced to try home remedies and explain to my children why we can't go to the doctor when needed.

Go figure,I work for a hospital…

Thank you.

OHSU employee in crisis

May 5, 2006 1:58:58 PM
Peter Kohler says

Dear Anonymous:

You are not alone. I am involved every day with individuals and businesses who have the same worries about the costs of health insurance and health care. While it is not a complete answer, one hope for this clinical trial will be that it will lead to a less expensive way to deliver health benefits. Thanks for expressing your concerns.

May 8, 2006 9:18:55 AM
sweet lou says

Anonymous, you shouldn’t be embarrassed because you certainly aren’t alone. Granted, it's ironic that healthcare professionals can't afford access to healthcare – like the old saying about the cobbler's children having no shoes – but it’s the same in pretty much every industry. I work for a nonprofit focused on health and human services. I certainly never expected to get rich working in the nonprofit sector, but I do get great personal satisfaction from the work. Each year, however, the cost of health insurance and deductibles continue to rise while our salaries remain basically the same. Eventually, I'm going to have to sacrifice my personal alignment with the mission to the economic reality of just paying my bills. This saddens me. Worse, nonprofits are shouldering an increasingly heavy load as the federal and local government divest themselves of safety net services, but if they can't even afford to provide adequate coverage to staff, how are they going to attract committed staff? I don’t know what the answer is, but I do know that if we keep letting the healthcare system lurch along towards the precipice, it’s going to drag us all over the edge with it…

May 10, 2006 11:33:38 AM
Ross Wiltzius says

Dear OHSU employee:

I’m the OHSU Human Resources director responsible for the development of medical and dental plan designs.

You need not be embarrassed by your struggles to pay for your health coverage, as your situation, unfortunately, is not unique. The cost of healthcare in the United States has placed many employers and employees in a precarious situation. Affordable healthcare is not available without cost sharing between employers and employees, and finding the balance between monthly costs (premiums) and reimbursement levels for care received is not always easy.

I encourage you to contact me directly to discuss your concerns, at 503 494-7617 or wiltzius@ohsu.edu. I may be able to suggest options you have not considered, as well as direct you to other OHSU resources for assistance.

Ross Wiltzius

May 17, 2006 7:58:12 AM
Teresa T. Goodell, RN,CNS,PhD says

Using less expensive non-physician providers is not really a new idea. I do applaud Dr. Kohler for championing the cost-effectiveness cause, but it is important also to note that many studies have shown that primary care provided by advanced practice nurses (APNs) such as certified nurse midwives and nurse practitioners is as good as or better than that provided by physicians. Most primary care can be handled expertly by APNs, and APNs readily refer complicated situations to our physician colleagues.
There are similar studies of physician assistants.

So quality of care is no longer the question. The greater problem is the barriers that exist to independent practice for APNs, such as difficulty obtaining Medicare provider numbers and lesser reimbursement for identical care. To make care by non-physician providers a reality, these obstacles must be removed.

May 18, 2006 9:41:20 AM
S. Shearer says

Prior post makes interesting points, but does not address the other part of the original column--potential of diagnostic computer software used by patients and MAs before ever getting to APN or any other caregiver. Would the computer side of it be appropriate for an independent APN practice too? Seems like the health care world has been slower than other sectors to adopt the potential of IT to lower costs and improve care, consider we are just now getting around to portable electronic health records...

May 19, 2006 1:18:05 PM
Peter Kohler says

The last two comments bring up important points. The decision-supporting software appears to be an improvement over the usual electronic health record. This potentially makes it easier for less highly trained individuals to serve as the interface to the client/patient, backed up by the team. However, the concept needs to be tested. The software might well expedite practice for APNs or others. That could be evaluated as well. Unfortunately, while barriers still exist for APNs, there will almost certainly be a substantial shortage of APNs in the future as the population ages and expands.

Oct 31, 2006 1:25:58 AM
John says

Study stats online.

Nov 11, 2006 11:08:31 PM
P.F. Jennings says

There is an article which came out recently. It follows right along with what is being said re "The Computer Is In" etc.

It is in the British Medical Journal:
http://www.bmj.com/cgi/rapidpdf/bmj.39003.640567.AEv1

The basic idea of the article is that doctors can use a Google search, combining their knowledge and specific words, and will do a better job of diagnosing rare diseases.

Better job than they would have done - (some doctors, at least) - without adding the Google search.

Sounds similar to what is being suggested here at Rx Healthcare -- except that for the difference between using assistants instead of doctors, as a beginning step.

What I don't understand: why don't ALL group practices that expect to diagnose anything, of any kind, already use these diagnostic computer programs - as an addition to individual doctor knowledge?

Nov 30, 2006 3:41:45 PM
Sara says

The WSJ wrote recently about a similar effort of the VA and Kaiser, here is a summary:

Wall Street Journal Examines Efforts by Kaiser Permanente, VA To Prevent Diagnostic Errors
[Nov 29, 2006]
The Wall Street Journal on Wednesday examined how Kaiser Permanente and the Department of Veterans Affairs "are leading new efforts to improve diagnostic accuracy." According to the Journal, "diagnostic errors are the Achilles' heel of medicine -- yet little has been done to prevent their deadly toll." Studies have found that diagnostic errors occur in 10% to 30% of cases and "generally stem from flaws in doctors' thinking, glitches in the health care system or some combination of both," the Journal reports. According to a 2002 study conducted by the Agency for Healthcare Research and Quality, diagnostic errors that might have changed patient outcomes are found in 5% to 10% of all autopsies. A study published last month in the Annals of Internal Medicine also found that of 300 closed medical malpractice claims, 59% involved diagnostic errors that injured patients.

Kaiser, VA Efforts
In response, Kaiser and VA have begun to use Internet-based "decision-support" programs, such as isabelhealthcare.com, that provide physicians with "an array of possible diagnoses they might not have considered" and prompt them to "perform appropriate tests on patients with certain symptoms," the Journal reports. Mark Graber, chief of medical service at VA Medical Center Northport in New York found that the Isabel system provided the correct diagnoses in 98% of cases. The Isabel system costs about $54,000 annually for a 300-bed hospital and about $500 annually for individual physicians and group practices. In addition to the Isabel system, Kaiser has begun "pilot-testing" the Emergency Medicine Risk Initiative, an Internet-based diagnostic tool for emergency department physicians. The tool prompts physicians and nurses to ask a series of questions, order certain tests and record their actions on a chart for patients who present with high-risk symptoms. Doug Bonacum, vice president of safety management at Kaiser, said, "There are so many things that can go wrong from trying to get patients in for an exam, to follow up after treatment that we need to take a more systemic approach." Stephen Borowitz, a specialist in pediatric gastroenterology at the University of Virginia Children's Hospital, said, "This is really a culture change for doctors. We have to face that we can't really know it all or carry all the medical knowledge in our heads" (Landro, Wall Street Journal, 11/29).

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Jun 28, 2011 11:00:32 AM
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