Quality care follows when health professionals collaborate

A message to all physicians from Ardis Dee Hoven, MD, chair of the AMA Board of Trustees.

By Ardis Dee Hoven, MD, an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11 Posted Oct. 18, 2010.

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There is much to be gained from working closely with other professionals. When each one is an expert in his or her own field and all are trained to work toward a mutual goal, individual contributions are magnified, and results are more than a single person could ever achieve.

Disease management, infection control, treatment of geriatric patients and public health initiatives all have benefited from the work of interdisciplinary teams. I believe physician-led multidisciplinary collaborations are going to play a big role as American health care evolves in the coming years.

Of course, physicians always have worked in teams of one kind or another. Even solo practitioners head small teams that include a nurse and an assistant. So while broad-based collaborative teams may seem new to patient populations, physicians should see them as a "next step" in American health care.

It only makes sense to work this way. Inevitably, successful collaborations result in quality improvement. Because of their interdisciplinary nature and because they require cooperation among the members, teams make fewer mistakes than individuals, thereby helping to avoid errors and ensure patient safety.

Two good examples of interdisciplinary team success in clinical and hospital settings are antimicrobial management committees and the task force approach to infection control.

Antimicrobial teams, which often include a combination of infection-control specialists, infectious disease specialists, clinical pharmacists and the microbiology laboratory, provide useful, real-time data pertaining to antibiotic choice and dosing to the prescribing physician, thereby effectively managing antibiotic resistance.

Likewise, infection control teams, which can involve representatives of most of the modalities practicing in the hospital, are able to look at the root cause analysis of why infections happen in the first place -- and then put plans in place to deal with them.

Because collaborative approaches to medical care are so important, the National Patient Safety Foundation has created an annual award to recognize outstanding examples.

This year, the NPSF awarded Virginia Mason Medical Center in Seattle its Stand Up for Patient Safety Management Award for a lifesaving program based on the work of a cross-discipline team. A highly targeted electronic medical records system that incorporates checklists specifically for congestive heart failure patients; a specialized patient education packet; regular, straightforward communication with patients about their condition throughout their hospital stay; and phone calls from clinical staff within 48 hours of discharge are all part of this interdisciplinary program. They all go to make sure that heart-failure patients have a seamless transition through the care process.

Partly because of their success in clinical and hospital settings, we are now seeing community-based medical teams being put in place all over the country. Although communication is harder and patient adherence is less sure in a community setting, many health care experts feel the community-based team approach will improve quality of health care and help curb ever-rising costs.

When physicians, hospitals, nurses, technicians, patient advocates and others collaborate, they can help prevent costly hospital admissions and keep patients from cycling between nursing homes and hospitals.

The most common example of a community-based team approach is the medical home, where collaborative teams of physicians, nurse practitioners and/or physician assistants provide office, hospital and home care. These teams make extensive use of telephone and e-mail consultations and electronic medical records.

The medical home model emphasizes consultation rather than referral, and successful medical home patients have greater care coordination, reduced hospitalizations and, ultimately, reduced costs.

As in hospital and clinical settings, community-based collaborations depend heavily on communication (both among team members and with patients) and patient compliance -- much harder to accomplish in the "real world." Clearly, EMR systems play a key role in any community-based medical team approach.

In his first major public address, Donald M. Berwick, MD, head of the Centers for Medicare & Medicaid Services, announced goals for CMS and specifically called for more community-based collaborations -- in the form of interdisciplinary accountable care organizations.

ACOs, which were named in the Patient Protection and Affordable Care Act, aim to integrate and coordinate the work of teams of physicians and health care professionals as a way of providing comprehensive care for patients.

As the law was written, ACOs can include physicians in various group practice arrangements, from multispecialty medical groups to networks of individual practices of physicians. In an ACO, health professionals work in teams and are supported by the organization's work flow processes, communications procedures and payment systems.

Ultimately, ACOs should provide vulnerable seniors, especially those with chronic conditions, with better disease management and better care coordination.

The AMA supports and applauds efforts to establish these community-based medical team models. However, we also want those models to be successful. Therefore, we have taken action in two areas that must be addressed if ACOs and other integrated health care teams are to become a viable part of our medical system.

Pay for specialists who are enlisted to consult with medical teams must be commensurate with the service provided, and antitrust issues must be dealt with for physicians in solo or small group practices.

In July, the AMA warned that the elimination of Medicare's consultation codes, which are used most frequently by specialists after a patient referral from a primary care physician, has had a negative impact on physician efforts to improve care coordination and reduced treatment options available to Medicare patients. (Data came from a survey by medical specialty societies and the AMA.)

More recently, the AMA has urged Dr. Berwick and the FTC to make clear that small and solo physician practices can collaborate around health information technology and quality improvement initiatives that make joint negotiation of fees necessary and justifiable, without incurring the sort of organizational costs that make it necessary for physicians to turn to hospitals.

These two important changes are key if collaborative health care is to become a significant part of the American system.

ACOs are only one form of interdisciplinary collaboration that we are going to see develop in this country in the coming years. If you think about the progression from small office-based teams to hospital and clinical collaborations to fledgling community-based efforts, you know this type of medical care will continue to evolve.

As time passes, new ways of collaborating will develop, all with the same goal: to help physicians provide the best possible medical care for our growing and aging American patient population.

Ardis Dee Hoven, MD , an internal medicine and infectious disease specialist in Lexington, Ky., is president of the AMA. She served as chair of the AMA Board of Trustees during 2010-11

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