How my Orthopaedic Surgeon saved me from Bowel Cancer
Bob W will tell you that his life was saved from bowel cancer by his doctor. The surprising thing in Bob’s story is that he is referring to his orthopaedic surgeon!
Bob is one of 8.6 million people cared for by Kaiser Permanente, a US health care organisation that looks after 8.6 Million people, employing a staggering 14000 physicians, and 160000 other staff. They provide all aspects of their customers’ health care needs – acute, preventative, routine, hospital care, allied health care,investigation and chronic disease management. In this ‘vertically integrated system’, they run 431 office practices and 35 hospitals.
If you are a patient of Kaiser’s, all your care needs are ‘pre-paid’ – if they can keep you healthy, then it will be easier and less expensive to look after you. They have both the usual ethical interest in keeping you well, as well as a huge financial one!
Kaiser have developed a ‘Proactive Office Encounter’ protocol as part of their system. Dr Michael Kanter is a physician and the Proactive Care Group Leader with Kaiser. He and Dr Ozzie Martinex presented at the IHI Forum in Washington this morning.
“Every time a patient has any contact at any of our services, his or her record is checked to make sure that they have had all of the health screening activities that are indicated – given their age, sex, history and other medical problems.”
Dr Kanter says that
applying this integrated and coordinated care delivery process has resulted in a positive impact on the lives of members in areas of cancer screening, blood pressure control, cardiac health, diabetes, asthma management, immunizations, tobacco cessation, weight management, and exercise.
Go in to have a mammogram, and they’ll let you know that you are due for a cholesterol check. Go to the ED with an acutely swollen and painful knee, and the orthopaedic surgeon will fix your knee – and send you home with a bowel cancer screening kit, if it is due.
All Good Now
Bob saw his orthopaedic surgeon with his crook knee one afternoon in the urgent care centre. She fixed his knee- and handed him the kit for his bowel screening, which he’d put off for a year.
He was surprised to get a call a few days later by his regular primary care doctor. A colonoscopy had been arranged for the next week, as the screen was positive.
The colonoscopy did show a cancer. He was booked for surgery.
The night before he was due to go in, the surgeon rang him at home at 7pm. Bob tells this part of the story with a tear in his eye. The abdominal MRI had shown a large renal tumour, which had to be dealt with first.
Now, according to Bob, its all good. “I’ve lost one kidney and one foot of bowel. No problem – I’ve got another kidney and still have four feet of bowel left”
System Changes
Think about this system – how many processes have to be done just right for Bob’s cancer to have been discovered.
For a booked appointment at any of their facilities, the ‘Proactive Office Encounter’ begins a week before the appointment is scheduled. An automatic service lets the staff know that the patient should have some preventative activities or other tests. Where practical, these are arranged beforehand, so that the results will be available when they come in – or the necessary test booked on the same day they are coming in to save a revisit.
For acute and unscheduled appointments, the necessary tests are flagged when the patient arrives.
The Proactive Office Encounter system will flag any other activities that should be done when the patient has arrived and before they see the doctor. All of these are done by the ‘Medical Assistant’. Any ‘labs’ required are signed off by the doctor, and the need for them is reinforced by the doctor
When Bob was seen in the urgent care centre, the medical assistant was notified of Bob’s ‘care gap’, even though this was not the usual office that Bob attended. The assistant included the bowel test kit in his papers, and informed the orthopaedic surgeon when he handed Bob over to her. It was made very easy for the surgeon to provide comprehensive care – as it should be. A good system should not be dependent on the individual delivering the care.
Culture Change
Dr Kanter says that it requires quite a culture change for many specialists to participate in a program like this. The POE system monitors how effectively the ‘care gaps’ are filled in each facility and by each physician within the system. (the ‘care gap’ is not considered closed when the test is requested, only when it has actually been done! “You can’t get away with saying that its not your job”.)
Tools
The tools that have been developed for the Proactive Office Encounter program include
- Standardd Office Workflows
- Condition Specific Workflows
- Phyiscian Specific Workflows
- POE Skills Inventory for Staff
- Training for staff (including videos of each step)
- Skill Validation Tools
- Performance Monitioring Tools.
- Chart Review Tools
- Workflow Efficieny Audit Tools
- Physician Surveys
eHealth Investment
Kaiser has invested heavily in eHealth throughout their facilities, and programs like the POE demonstrate the opportunities that are only available when health records are linked across a system.
The electonic medical record system Kaiser Permanente HealthConnect is used in all their facilities nationwide. The data it contains is up to date, coded, and available anywhere. They have accurate disease registers and use these to facilitate proactive and systematic management. As well as preventative and disease specific preventative health prompts, physicians have decision support tools built in to the medical software.
Patients have access to their health information via their web portal kp.org. Post consultation instructions and follow up arrangements, including recommended screening tests, and available to the patients immediately after their visit. Patients can also be contacted by secure email through this system, and contact their clinicans.
Has it worked?
Dr Kanter says that measurement and data are the key to pulling a program like this together. They collect data at every level, including a “Successful Opportunities Report” and a “Clinical Strategic Goals Report” to make sure that the changes they have made are leading to improvements.
Kaiser has documented how many lives have been saved through their many screening programs.
Since the POE was introduced in 2007, there has been improvement in Kaisers clinical strategic goals. One thing I find amazing in these figures is from a very high base rate of screening – and still were not satisfied with that.
| Clinical Strategic Goal | 2006 | 2007 | 2008 |
| Breast Cancer Screening (Ages 52-69) | 85.6 | 88.1 | 88.7 |
| Cervical Cancer Screening | 82.0 | 85.6 | 86.6 |
| Colorectal Cancer Screening | 52.5 | 65.5 | 69.7 |
| LDL-C screening (CVD patients) | 93.6 | 95.5 | 95.3 |
| Controlling High BP (Ages 18-85) | 70.4 | 72.8 | 79.6 |
| HbA1c testing (Diabetes) | 88.8 | 90.8 | 91.2 |
| Eye exam (retinal) performed (Diabetes) | 61.6 | 56.3 | 66.5 |
| Lipid screening performed (Diabetes) | 88.6 | 91.0 | 90.4 |
| Nephropathy monitored (Diabetes) | 92.5 | 94.0 | 93.7 |
| Blood pressure control < 140/90 (Diabetes) | 76.1 | 74.0 | 79.5 |
| Influenza immunization rate (members 65+) | 60.2 | 62.0 | 62.0 |
| Advised Smokers to Quit | 53.0 | 63.0 | 67.0 |
| Offered Strategies or Meds | 35.0 | 43.0 | 49.0 |
The POE system is supplemented by an ‘outreach system’ (mail and email) for people who have overdue tests and haven’t been in. Dr Kanter says that given the success of the POE they will soon introduce a Proactive Inpatient Encounter System for hospital patients.
Many practices are using Doctor’s Control Panel to match up the patient’s screening requirements with the RACGP ‘red book’. Imagine this being available proactively throughout the entire health system!
How are you going in your practice?
Do you deliver evidence based care to every single patient, every single time?
Please share your story, or your comments, below.
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