Putting Patients First: Research, Physician Education and New Models of Care
Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality (AHRQ)
AMA Medical Student Advocacy Day
February 11, 2013
Good morning, everybody. Thank you very much for inviting me to be a part of this event. It is very encouraging to see that all of you understand the need for physicians to be not only practitioners, but advocates of health care, and I'm very happy to have this opportunity to talk to you about current and future issues of quality improvement in medicine and how they will affect future practice.
This is an exciting time to be a part of the profession. A lot of momentum has been generated for health system transformation and new laws have provided unprecedented resources for change. Of course, we have a long, long way to go before we achieve the patient-centered, information-rich, evidence-based system that we envision. In keeping with this theme, I have two stories for you.
The first is about Dr. Eric Topol, director of the Scripps Translation Science Institute in southern California, a prominent cardiologist and leader in the field of wireless medicine. He was on a flight from Washington, DC, to San Diego when a passenger began having severe chest pains. Dr. Topol offered his services after the pilot asked if there was a doctor on board. Topol had been in Washington to demonstrate a prototype device that can perform an electrocardiogram using a smartphone. He connected the AliveCor device to his iPhone to perform the ECG mid-flight. The results showed that the passenger was having a heart attack, so he recommended an urgent landing. As a result, the passenger was rushed to the hospital and survived.
Story Number Two: Last month researchers in the United States revealed that they had spotted genetic changes caused by ovarian and endometrial cancers. They said the discovery offers promise for a new screening test for these two deadly forms of cancer. Right now, there are no tests that can reliably detect either one. Of course, there is a catch and I'll quote a Reuters article from January 9: "Experts say that although the test has tremendous potential, it is still years from widespread use."
Dr. Topol's story gives us evidence of the amazing breakthroughs that are taking place in health care. The cancer story brings us right back down to earth with an age-old issue: How do we reduce the amount of time it takes to get new tools and information into practice? How do we get ourselves on track to improve quality, access, safety, and so forth at a much faster pace?
We're currently in the process of switching from a system that is based on learning by experience, to one that is much more firmly grounded in using data and empirical evidence. This may not feel like much of a change to you. That's because you're a product of the current age. But the reality is that your excellent faculty was trained the old way—and that culture continues to dominate. In that culture, you see one patient at a time, you do the very best you can and then you move on. Now, we're shifting to one where it's becoming routine practice for us to say, "Okay, how am I doing?"
I think another major change is how communication and information technology are becoming a bigger and bigger part of health care. More and more, patients are using smartphones and other devices to get medical advice, and new and better products and tools are coming online to address the growing demand.
We're funding several studies that involve exchanging text messages with people. In one project, researchers at Wayne State University are working to develop a mobile phone text messaging system to improve hypertension medication adherence among African Americans. The goal is to build an innovative, adaptable, and very scalable system that has the potential to become a national solution. And the target audience will play a major role in the development of the intervention.
All of this means that the way we live our medical life is getting much closer to the way we live in real life. It also means that many other people will have a voice in what's taking place in medical practice. To me, that's a good thing. Getting people more engaged in their own health and health care—and giving them a seat at the table when decisions about the future of health care are being made—is extremely important. We know from studies that people who play a big role in their own care have better outcomes. My niece Maggie, for example, recently was diagnosed with diabetes. She uses her smart phone to monitor her blood sugar. She's part of your generation of Americans who grew up with this kind of technology.
For doctors, a major benefit of technology is that we'll be able to know how patients are doing over time. That's not possible right now.
We're funding a very large study on creating a patient registry for people who have hip and knee replacements. The orthopedists are very interested in this because they usually don't see their patients after surgery. They don't know what happens to clients unless they run into them on the street—or if they have an extreme complication and come back to them for additional treatment.
I also have to say that movement in this direction is a little scary for me personally, because we know that 80 percent of diagnoses are still made based on a patient's history. And I worry sometimes that we'll end up drowning in all of this data, which has the potential to drown out the patient.
It's a little like being in an ICU. We've got all of these gizmos, and the readings are normal, but the patient is still having a hard time breathing. There's a technological dimension, but at the same time, it's not all that different from what medical care has been over the ages, right? Some people come in and are incredibly thoughtful and reflective about their symptoms. Before you get through your questions, they've given you the entire download, while other people simply say, "I don't feel good."
When I was in training, I think there was an expectation that you'd reach some level of expertise in your particular area and then you were pretty much done. You took the board exams once and you kept up with new developments, but it was implicitly understood that any tweaks and refinements would be minor. Now we know how fast medical knowledge changes. We know that data from practice is going to be a big part of that. We also know that this means figuring out how to measure quality of care is a work in progress.
Several years ago, I reviewed what was basically the same article for multiple journals. Each one was critical of a pneumonia measure gauging whether patients got timely antibiotics. As a result of the measure, staff members were getting dinged if a patient was thought to have pneumonia, but didn't get the antibiotics. Of course, this led to overuse of antibiotics, inaccurate diagnosis, and other avoidable consequences. My response to the articles consisted of three words: We know that.
What we needed to know was how the measure could be tweaked or otherwise improved. How do we get better? How do we make sure clinicians, consumers, and policymakers have the latest and best information available for making decisions about health care?
That's the type of information we need. I can't tell you how receptive to this my colleagues at the policy level are to this now, and I'm quite confident this will continue to be the case in the future.
When you buy a television, a car, a new iPhone—fill in the blank—you go online to get information. People want the same type of information in health care. They want the same information about doctors. However, for some doctors, the prospect of online patient reviews can feel a little scary and a bit unfair. That's understandable under the circumstances. When you try to book a hotel reservation online, you find some great reviews. And then there are others for the same hotel, where guests describe roaches casting shadows across the carpet. So, you have to figure out which is the most accurate. But it's part of the brave new world we live in. I expect, if anything, doctors will become more engaged with social media.
We don't know what that will look like, much in the same way that 10 years ago many of us would not have predicted that smartphones would becomethe tool for all kinds of health care apps, including one that can perform an ECG at 35,000 feet. It's difficult to determine what will take off in the next 5 years. One thing we do know is that things will be very different than they are now.
People often ask me to name two things that can happen everywhere to make health care better now and in the future. My first response is always remember to repeat what you've said to them—"Tell me what you heard."
My other suggestion is to make sure you establish a routine period that you use to look back. What mistakes were made? Exactly where did we drop the ball? We have to become more open to taking opportunities to learn from our mistakes.
The other piece of advice I have is for those of you who know right now that you want to be in policy. I certainly wasn't there in med school, but I had colleagues who were. If this is true for any of you, I can't urge you strongly enough to get clinical training first. It makes a big difference. We've had young physicians apply for a variety of programs at AHRQ, and it can be a difficult climb without clinical training.
In the previous administration, there was a lot of excitement about price transparency. At one point, a group of people who were not clinically trained brought spreads sheets, charts, and other types of information to then Secretary Michael Leavitt to help support their strategies on the subject. They chose chronic obstructive lung disease as the diagnosis of choice for this activity.
And as the Secretary was looking at the information, he asked, "What's happening with the patient before he or she is admitted? If I'm the patient, what's going on with me?"
I said, "You're having a really, really hard time breathing." And right in that moment, he understood that price transparency would be something that would be helpful for some decisions, but not all decisions. So I think it's very important for policy people to have a clinical background, to better understand some of the medical challenges that are encountered on the front lines of care.
I would also urge those of you who are interested in becoming engaged in initiatives like system transformation to seek out opportunities and electives when you're a resident—or even summer internships—to work at AHRQ or another organization. Depending on what State you're in, there may also be opportunities at places such as the State department of health. Most of all, I would suggest that you enjoy this period in your journey. When you look back 20 years from now, you are going to be amazed at how much the system has changed. Everything you are looking forward to today, and have found to be exciting and interesting, is going to seem absolutely prehistoric.
At the end of the day, it's about applying the science to patient care. That's where we start, and that's where we end.
Thank you very much. Best of luck wherever this immensely challenging and fabulously rewarding profession takes you.