ABIM: Quality medical care needs more than strong systems

A guest column by the American Board of Internal Medicine, exclusive to KevinMD.com.

by Christine Cassel, MD, MACP

ABIM: Quality medical care needs more than strong systems Imagine a sub-par doctor at a vibrant health system with care delivered and coordinated by skilled teams, using robust EHRs and other vital supports for physicians and patients. Now imagine an extremely talented, knowledgeable doctor at an underfunded community clinic. This clinic has no real computer system, fewer staff and no linkages to subspecialty care. Where will a patient get better care?

It is not an easy answer, is it?

Physician skill and knowledge alone will not determine quality of patient care. And strong and supportive health care ‘systems’ or ‘medical homes’ will not determine quality either. Research conducted by my colleagues at the American Board of Internal Medicine (ABIM), and appearing in Health Affairs last week bears this out.

Good doctors can compensate for poor systems and good systems can compensate for poor physicians to a certain degree, but neither combination is desirable or sustainable for delivery of quality health care. And a poor physician in a poor system could be a disaster for patients.

Why is this important? Because it showcases that the current conversation about systems measures and accountability may be missing a fundamental point. As Eric Holmboe and colleagues noted in their Health Affairs article, “Measurements of practice structure are insufficient for assessing the quality of patient care.”

A qualified medical home is just a “tent” if the physicians within are not also meeting standards for knowledge and practice performance. And the physician who scores highest on the ABIM exams, if not given the tools and supports needed to effectively practice medicine will not deliver the highest quality care he or she is capable of. Physicians and the systems in which they work are inextricably linked and together determine the quality of care delivered to patients.

Consumers, physicians, and policy makers are calling for a renewed focus on coordination of care through new care delivery models, including the medical home or accountable care organization. These models require a primary care physician that provides comprehensive, coordinated, patient-centered care. To date, the medical home models have tended to focus more on system structures and less on the qualifications, skills and knowledge needed by physicians and other professionals to be successful in those models.

In 2007 the ABIM Task Force on Comprehensive Care Internal Medicine issued a report and noted “The need of patients for coordinated, patient-centered care in an increasingly complex and fragmented health care system has led us to confront the question of what specific knowledge and competencies might be required for successful practice of internal medicine in the 21st century, a practice that adds value for patients and the delivery system as a whole.” It is three years later and the answer seems clear.

Physicians need new knowledge and skills – including the ability to manage teams, information, resources and population-level data. More specifically, doctors need special expertise in longitudinal care for a population of patients – built by a trusting, personal relationship that is not limited to site of care, organ system or disease type. These primary care physicians need to be skilled in many areas of clinical medicine, able to use information technology, facilitate care teams to deliver and/or support the right care when and where it is needed, and reliably communicate important clinical information about their patients throughout the delivery system and directly to the patients and their families. Yet, our current model of physician training and assessment does not address many of these core comprehensive care competencies.

We can define the elements of a strong system, and we have an idea of the skills and knowledge needed for physicians to thrive in such environments. Now we just need the will to transform education, assessment and care delivery to bring together professional skills with effective systems to take the best care of the most complex patients.

Christine Cassel is President and CEO of the American Board of Internal Medicine.

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  • R Watkins

    “primary care physicians need to be skilled in many areas of clinical medicine, able to use information technology, facilitate care teams to deliver and/or support the right care when and where it is needed, and reliably communicate important clinical information about their patients throughout the delivery system and directly to the patients and their families.”

    It’s interesting that you didn’t include anything about the physicians needing to be paid for doing all this work.

    After 10 years of hype, still no one is willing to pay the docs for taking on all these additional responsibilities.

  • R Watkins

    To follow up:

    Group Health of Puget’s Sound transformation of one of their clinics into a “medical home” is being widely praised as a shining example of what primary care needs to become.

    However, if you read the details (American Journal of Managed Care, September 2009, available online) you find that, to do all the work detailed in Dr. Cassel’s post, physician staffing was increased by 15%, nursing and other support staff by 20%, and the patient panel was reduced by a full 25%!

    I don’t think that’s a viable model for the future of primary care in this country.

  • http://placebojournal.com Doug Farrago

    Can you define “quality” for me?

  • Doc99

    Any home will eventually collapse without a strong foundation. I’ll go with a good doctor over a good system anytime.

  • http://thehappyhospitalist.blogspot.com Happy Hospitalist

    You start out the story describing a “sub-par” doctor.

    Why would we have sub-par doctors if the doctor is paying several thousand dollars for board certification with the ABIM.

    Is it possible that going through the hoops for board certification and paying all that money does not guarantee the doctor won’t be sub par. And if so, why should physicians do it?

    • http://www.abim.org Chris Cassel

      Happy Hospitalist – as you probably know, board certification is not a requirement for medical licensure or to practice medicine, it is a marker for the public that a physician has met and is maintaining a standard in their chosen subspecialty.

      Chris Cassel

  • http://placebojournal.com Doug Farrago

    Dr. Cassel,

    I am sure you read the comments on the blogs that you post (we all do) so I want to ask one more time – can you define “quality” for me? Or how about “quality health care”?

    Doug

    • http://www.abim.org Chris Cassel

      Doug – I think the elements of quality care delivery include those mentioned in the blog post– a trusting physician/patient relationship, supporting the right care when and where it is needed, strong teams and the ability to communicate important clinical information to patients throughout the delivery system and directly to the patients and their families.

      Chris

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