An introduction to technology for patient-centered, collaborative care

"Patient-centered, collaborative care" is healthcare jargon. But underlying the jargon is the principle that a patient who receives such care strongly agrees that "I receive exactly the healthcare I want and need exactly when and how I want and need it." Currently only about 1 in 4 Americans who have adequate financial resources can make this claim. Think of a pyramid. At the apex is the highest level of "patient-centered, collaborative care." At the base are measures about "what's the matter" (from the clinical perspective) and "what matters" (from the patient perspective). As patients and clinicians act collaboratively on these measures, they climb closer to the apex of the pyramid. Given the realities of healthcare in the Unites States, should busy professionals take time to think about ways to climb pyramids? In this "Introduction" we describe why the answer to this rhetorical question ought to be "yes." In the articles that comprise this issue, readers will learn how technology that supports patient-centered, collaborative care can help bridge the gap between desirable goals and limited time. All the authors understand technology (such as hardware and software), and the way humans use the technology (called techne) will not overcome the many obstacles to the attainment of patient-centered, collaborative care. Nevertheless, we are hopeful that the examples described in these articles suggest ways that significant progress toward patient-centered, collaborative care can be made. The articles are practical. The results are persuasive. It is worth the climb!     

The emergence of Ideal Micro Practices for patient-centered, collaborative care

Ideal Micro Practices are capable of delivering patient-centered collaborative care. With respect to comparable adult patients in "usual" care settings, twice as many patients who use Ideal Micro Practices report they receive care that is "exactly what they want and need exactly when and how they want and need it" (68% vs 35%). Compared to usual care, these very small, low-overhead practices are more likely to have patients report very high levels of continuity (98% vs 88%), efficiency (95% vs 73%), and access (72% vs 53%). Patient ratings of very good information (83% vs 67%) and clinician awareness of pain or emotional problem are also higher (87% vs 69%). However, only a slim majority of patients using Ideal Micro Practices report that they are confident in their ability to manage and control their health problems or concerns. Ideal Micro Practices are sharing new tools and approaches to better understand their patients' needs and increase patients' confidence in their ability to manage conditions. In addition, these practices are working collaboratively to standardize their approaches and make the essential elements of Ideal Micro Practice replicable.     

Dynamic multistage scheduling for patient-centered care plans

We investigate the scheduling practices of multistage outpatient health programs that offer care plans customized to the needs of their patients. We formulate the scheduling problem as a Markov decision process (MDP) where patients can reschedule their appointment, may fail to show up, and may become ineligible. The MDP has an exponentially large state space and thus, we introduce a linear approximation to the value function. We then formulate an approximate dynamic program (ADP) and implement a dual variable aggregation procedure. This reduces the size of the ADP while still producing dual cost estimates that can be used to identify favorable scheduling actions. We use our scheduling model to study the effectiveness of customized-care plans for a heterogeneous patient population and find that system performance is better than clinics that do not offer such plans. We also demonstrate that our scheduling approach improves clinic profitability, increases throughput, and decreases practitioner idleness as compared to a policy that mimics human schedulers and a policy derived from a deep neural network. Finally, we show that our approach is fairly robust to errors introduced when practitioners inadvertently assign patients to the wrong care plan.

     

Provider-sponsored coordinated care organizations: designing systems for patient-centered care

PCCOs should take inventory of the information demands in the critical areas of quality, resource, and outcomes management, and standardize the data elements and definitions as the enterprise data model. The focus must be on internal and external reporting requirements as, ultimately, the data model must expedite clinical practice improvement initiatives. The Informational Processing Architecture utilizes the data warehouse for enterprise decision support to derive clinical/business rules and the operational data store/applications for clinical decision support to deploy those same rules at the point of care. As a result, clinical and financial systems should be tightly linked, associating outcomes, process, and cost. In designing these systems, the Systems Development Life Cycle methodology has the advantages of documented deliverables and a well proven methodology for outlining requirements put forth in an RFP, which is indispensable for vendor evaluation and selection. Employing these techniques ensures a user driven process that has the best chance of implementing the complex requirements of PCCOs.     

Discussion of patient-centered care in health care organizations

The tradition of inherent knowledge and power of health care providers stands in stark contrast to the principles of self-determination and patient participation in patient-centered care. At the organizational level, patient-centered care is a merging of patient education, self-care, and evidence-based models of practice and consists of 4 broad domains of intervention including communication, partnerships, health promotion, and physical care. As a result of the unexamined discourse of knowledge and power in health care, the possibilities of patient-centered care have not been fully achieved. In this article, we used a critical social theory lens to examine the discursive influence of power upon the integration of patient-centered care into health care organizations. We begin with an overview of patient-centered care, followed by a discussion of the various ways that it has been introduced into health care organizations. We proceed by deconstructing the inherent power and knowledge of health care providers and shed light on how these long-standing traditions have impeded the integration of patient-centered care. We conclude with a discussion of viable solutions that can be used to implement patient-centered care into health care organizations. This article presents a perspective through which the integration of patient-centered care into health organizations can be examined.     

Hormonal contraception,breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.