You can listen to the episode here.


[00:00:02] Stacey Richter: Episode 431, "How Accountability for Outcomes Works in the Real World". Today, I speak with Dr. Kenny Cole.  

American Healthcare Entrepreneurs and Executives You Want To Know Talking. Relentlessly Seeking Value.  

The Complex Reality of Healthcare Strategy

[00:00:29] Stacey Richter: There's this meme that's going around on the interwebs with the caption, sometimes the shortest distance in between two places isn't a straight line. What? Yeah, because actually there's three dimensions in the real world. See the link in the show notes.  

So when we all consider the real world, understanding the contours of reality and aligning with them is the only way to devise a winning strategy. Not only if you're timing rubber balls getting dropped off straight or curved slopes.  

The Pitfalls of Oversimplification in Healthcare

[00:01:00] Stacey Richter: I'm saying this because I've seen, and you've seen, a whole lot of great ideas fail. 

Because someone draws a very elegant straight line on a whiteboard, calls it the fastest and most efficient way to get from here to a desired outcome, and then the plan ultimately fails. What contours am I talking about taking into account right now?  

Exploring the Contours of U.S. Healthcare

[00:01:20] Stacey Richter: Oh, pretty much the entirety of U.S. healthcare. If you combine the complexities and perverse incentives of the industry itself, plus the art and science of medicine, plus epidemiology and social determinants, and I'm probably forgetting other dimensions, you have contours that are mountain ranges. 

Not considering the reality of those elevations and just thinking there's some kind of straight line here to be found is really a kind of delusion. Now, investors and C-suites may like these delusions, but let's just get real. It's not going to actually work out as written.  

Case Study: The Missteps of Digital Health Solutions

[00:01:52] Stacey Richter: One case study that I am talking about is digital health solutions, or pharma companies even, or pretty much anyone who thinks that the fastest way to increase sales is to talk about the product, let's just say is one example. 

That's the straight line to growth. Talk about the product. Another one is stripping away things that feel like they're a waste of time in the name of efficiency. Without actually checking if you're cutting into essential stuff. I talk about this at length with Kate Wolin in an episode coming up. 

Jodilyn Owen has a thing or two to say on this point in episode 421 also. But let me be clear, I'm not talking about anyone listening to the show today making this mistake, at least wholesale. We all make it incrementally, it's hard to avoid. But you get this. That's why you're here.  

Understanding Customer Problems: The Key to Success

[00:02:39] Stacey Richter: You get that the fastest path anywhere is truly understanding the problems faced by customers, and then it's showing how the product, or whatever you're doing, helps solve those problems. 

No one cares how efficient or safe your thing is if it's accomplishing something that no one cares about. No one gets paid for and or can figure out how to deploy or use. This is what the entire episode last week, episode 430 with Barbara Wachsman, was about.  

Why Relentless Health Value Matters

[00:03:09] Stacey Richter: Why is all of this relevant? It's actually what makes Relentless Health Value relevant, frankly. 

Many listeners, and shoutouts to Nate Walker and MaryCarol Evans, Many listeners say that this is why they listen to Relentless Health Value and what Relentless Health Value helps them with, finding those contours, understanding reality so that it can be aligned with and on the show today, Dr. Kenny Cole, I got to say could be really impactful in this regard, as well as in others.  

Dr. Kenny Cole on Clinical and Financial Success in Healthcare

[00:03:40] Stacey Richter: Dr. Kenny Cole is from Ochsner Health System, and I love this conversation today because it has lessons for anybody working in a clinic or managing a clinic who wants to learn from a master. But it also is really interesting for anyone who's trying to work with, alongside of, or sell to, a clinical practice or health system that is pulling away from the status quo. 

That is standardizing care and working as a team, one that is earning the trust of its patients and also one that is figuring out how to reinvent the business model of healthcare such that clinical pathways and care flows are aligned with financial viability. That's really obviously the holy grail here. 

We talked today about how to achieve clinical and financial success. Even if the financial models are all over the map, we talk about how to create a practice model or a clinical model that might appeal to clinicians and keep them from being burnt out, while at the same time ensure that patients are getting the kind of outcomes everyone can be proud of. 

And the place doesn't go bankrupt either. This episode reminded me a lot of the conversations with Dr. Scott Conard. There's lots of complimentary points. The shows with Dr. David Carmouche from when he was at Ochsner is also pretty relevant here. Some of the points that Dr. Kenny Cole makes today also align very much with what Rik Renard was talking about a few weeks ago. 

But regardless of where you sit or what you're trying to do, this show is a great one to really get a bead on the lay of the land to find the actual shortest path between here and there, which is not gonna be most likely an obviously straight line.  

The Four Main Points by Dr. Kenny Cole

[00:05:18] Stacey Richter: Dr. Kenny Cole makes I'm going to say four main points by my counting and they are as follows. 

Point one, clinical teams have to deliver care wherein outcomes are measurable and it has to be done in such a way that those clinical teams are accountable for the outcomes that are generated. Point two, clinical teams need to really see with their own two eyes and believe that a clinical goal that they've been given is possible. 

Number three, care flows are critical here, which means getting everyone on the same page about what best practice care looks like and operationalizing how that clinical excellence will be achieved. And number four, last point, building trust with patients and connecting with patients cannot be underestimated. 

And care flows need to not only standardize care so that it can be delivered quicker and easier, but also facilitate patient relationships. Dr. Kenny Cole is a primary care internist. He sees patients one day a week. The other days he serves as a systems vice president for Ochsner Health, which is a large integrated delivery system. 

In this role, he designs and develops new care models. I made a bunch of recommendations in the show notes for shows that you might want to consider listening to next. Oh, two last things and new topics. First, thanks to Santos L. Halper, Nina Lathia, and KC64789 for some really nice reviews this month. I read them. They make me happy. Thanks so much for leaving them.  

And lastly, heads up, that Rule of Three has an annual March healthcare classic that is currently ongoing. Links in the show notes. It's pretty cool what they do. They have a very August panel that debates which trends will reign supreme in their impact on healthcare in 2024. 

The committee includes Dr. David Carmouche from Walmart, Eric Gallagher from Ochsner Health Network, Leah Binder, who is the CEO of Leapfrog. And Anisha Sood from First Choice Health, so check it out.  

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group,  

Dr. Kenny Cole. Welcome to Relentless Health Value. 

[00:07:32] Kenny Cole: Thank you for having me. Nice to be here.  

[00:07:34] Stacey Richter: I'm trying to figure out how to kick off this interview to make a really strong point.  

Optimizing Care Pathways: A Real-World Example

[00:07:40] Stacey Richter: The point is that in many chronic conditions, such as diabetes, which is one big kahuna of a chronic condition, but there's a treatment plan, a clinical pathway that is in fact optimal. 

So maybe let's start here. Could you give me an example of an optimal care pathway? where there may actually be a lot of care variability, treatment variability, just so that we can get grounded in a real world example.  

[00:08:08] Kenny Cole: Yeah, let's just take that example of metformin. You're not going to find any disagreement among clinicians that metformin should be the foundation of pharmacotherapy for the treatment of type 2 diabetes, but where you are going to find lots of clinically unwarranted practice pattern variation, you're going to is in how many or what percentage of patients who are prescribed metformin are able to tolerate it in a way that they're taking it without suffering from the GI side effects. 

And so when you're corralling that clinically unwarranted variability, you have to begin to look at every single variable that may potentially cause that person to not be able to tolerate the metformin. You're doing things like level setting the expectation, you're assuring the patient that the overwhelming majority of people will tolerate it as long as they take it with food and that the type of food they're taking it with matters tremendously that when they get the balance of protein to carbohydrates wrong and if they have too many carbohydrates. 

That's when they're going to get the GI side effects. And so I, for example, I would have a smart freeze embedded within my electronic medical record that's simply called tolerating metformin. I wrote it myself. I give examples of the types of foods that they could use to balance out and take it. And then what you do is you just engage in these iterative and recursive loops of learning, right? 

Because anytime you have a patient who's not tolerating it. You're immediately digging in of, okay, why, what happened, let's go through your meals, let's understand what you did, what you could have done differently, and then you're educating and you're just continuing to do that until you have achieved as large a proportion as possible of your patients tolerating metformin, which over the last several years, I've typically been 98, 99%. 

[00:09:57] Stacey Richter: As you were talking, I'm thinking about a couple of different things. One of them is that 98 or 99 percent of patients on metformin, which is a gold standard here, as you said, is amazing. Many patients can't take metformin due to these GI side effects and then they wind up either with disease progression or on other drugs that are maybe more expensive and obviously they weren't the first choice because the patient had to fail on metformin, which was the first choice. So you wind up with large swaths of patients, a big proportion of a population, not getting the gold standard pathway for reasons that are maybe overcomable, if that's a word.  

Building Trust and Patient-Centered Care

[00:10:41] Kenny Cole: In these new models of care that I design, one of the things that my doctors, I will teach them very early on is it is not the patient's job to comply with what we tell them to do. It is our job to earn their trust and then go on a journey with them where we help them to accomplish what matters most to them. 

So, for example, my physicians know that the one word that I don't ever want to hear in any of our clinics is the word noncompliant, where we basically label a patient as noncompliant because they failed to do what we told them to do. And I don't really like nonadherent any better. It's a slightly kinder, gentler version of noncompliant. 

It's not about them complying or adhering to what we tell them to do, it's about how effective are we at communicating and building that trust and building that rapport and then in essence leading them. On a journey where we coproduce a desired health outcome, preferentially one that matters most to the patient themselves, so that we're appealing to their intrinsic source of motivation. 

[00:11:48] Stacey Richter: What you're saying is, it very aligns with the conversation that I had actually with Dr. Robert Pearl about how to lead healthcare transformation. And one of the things that he said, which struck me, and I mulled over it actually for a I'm still mulling over it maybe, is how the art and science of medicine fits into this conversation or even fits into how care is standardized. 

And what he said was there is a science of medicine. I mean not all the time, there's plenty of circumstances where there actually isn't a whole lot of evidence. So let's just take those off the table right now. If we're talking about a circumstance like this diabetes patient where there's a ton of evidence relative to what is the right treatment plan, that's the science of medicine. 

And the only time that science of medicine should be deviated from is based on the patient preference. And that's the art, what the patient wishes to coproduce with you.  

[00:12:40] Kenny Cole: That's right. For example, I still do see patients one day a week and I am and want to be held fully accountable for the outcomes that I am coproducing with those patients. 

And so if a patient is not taking a medication the way that I would want them to or so forth, then it is now my job to uncover the barriers, the obstacles, the challenges. It may very well mean having to correct some type of misperception that they may have. I've told other physicians that like, look, if a patient is not taking the statin, that you prescribe them because their neighbor's uncle developed bad muscle aches while taking it and they're just now scared. All it means is they trust their neighbor more than they trust their doctor. And so part of what the doctor needs to be able to do is to earn that trust. And I think that's the most essential and most important part of that doctor patient relationship is building that rapport and earning that trust. 

Once you do that, now you have this clear path to be able to unleash the science in a way where the patient trusts the science because they trust you, the doctor.  

[00:13:52] Stacey Richter: I'm trying to contemplate everything you are saying from a, let's improve the health of this entire population standpoint. So figuring out how to operationalize the ways that you are training your clinical team and just in the real world execute consistently across the whole patient population, you know, not have some patients some of the time get some of what might be considered best practice care, depending on which clinician they see or what day it is. 

The Importance of Care Flows and Standardization

[00:14:20] Stacey Richter: And we had a conversation about this before, actually, you and I, and you said, let's begin with the end in mind.  

[00:14:26] Kenny Cole: You do start with the end in mind. And so that is going to be the outcomes that matter most to the patients, right? I've never met a patient who wants to go blind from their diabetes or who wants to be debilitated by a stroke or who wants to have heart failure because they spent years of with uncontrolled hypertension. 

And what we have failed to do thus far in healthcare is even really. Define what health is, for example, sticking with the theme of diabetes for a moment, somebody who's at the greatest love of their life is fishing and they know that basically fishing, you've got to be able to have good sensation to be able to feel that line when a fish bites. 

In order to appeal to their intrinsic source of motivation, I want to be able to help them fish for as many years as I possibly can. But essential to that is going to be the control of their diabetes. Instead of some arbitrary, our goal was to get your A1C less than seven, which may not mean that much to the patient. 

Our goal is for you to be able to fish for as many years as possible and to do that we've got to prevent the numbness that's going to come in your fingers and your feet. And in order to do that, we're going to have to control your sugar. And what that control of your sugar looks like is going to be an A1C of seven. 

And that's going to be the measure that we're going to use to make sure we're achieving that goal that matters most to you. And so fully interpreting it in that way and then backing out from there in order to then begin with what the care flow looks like from the beginning.  

[00:15:54] Stacey Richter: Here's my big question. I have a conundrum for you, Dr. Cole, because you're delivering clinical excellence to your patients. I mean, if you have 90 plus percent of your patients on metformin and you told me before that you think 95 percent blood pressure control is what the standard should be, which is going to blow some people's minds right now because across the rest of the country if blood pressure is 70, 75 percent controlled, people think they're doing amazing work. 

So we have this situation where. You've got an amazing clinician who knows how to have the conversation about fishing and who sets up the conversation in that way, then you get patients who are intrinsically motivated because they understand what the risk is here and we're giving them a sense of control. 

Here's how you can monitor to make sure that you don't wind up having these risks. It makes a ton of sense. On the other hand, you're going to talk to a lot of clinicians like Dr. John Rodis is a medical director over at QC Health and we're doing a lot of stuff with kidney disease. We've had plenty of conversations with clinicians who don't tell their patient that they have progressing kidney disease because, in air quotes, they don't want to scare the patient. 

So I'm trying to figure out, how do you do this at scale then? How do you do this across the organization? What does that whole organizational process, is it training? Is it really strict processes? Is it, I don't know, like, how do you scale clinical excellence?  

[00:17:27] Kenny Cole: The first thing is you show it can be done, like you show what is the new standard of care for what should be acceptable because yes, I do believe that the future standard of care will be that anything less than 90 to 95 percent rates of diabetes control is going to be considered substandard. 

Anything less than probably 95 percent rate of hypertension control is going to be considered substandard. Again, in terms of your chronic kidney disease question, it goes back to that whole question of trust. I often tell patients in my first visit or first or second visit with them, I'll ask them what their goals are, but I'm going to let them know that I only have one goal and my one and only goal is to earn their trust. 

And then once you earn that trust, you can't betray that trust by not telling them about their chronic kidney disease. Instead, you have to be open and honest about what you're seeing with their glomerular filtration rate declining and where it is and you might even want to go ahead and calculate after you of course get their albumin and creatinine ratio, you would calculate the kidney failure risk equation, both a two year and five year risk. 

You can let them know what the percentage looks like. But then you can let them know that you're right there with them and that the goal is that we can reverse that. That we can actually by better controlling blood pressure and by better controlling diabetes and by making sure that we're addressing the cardiovascular risk factors appropriately to reduce the risk of cardiovascular, you know, an adverse cardiovascular outcome because of course that is the leading cause of death even in chronic kidney disease. 

That you're right there with him and that you're going to do it together and that here's how we're going to get there together. And you lay out that scenario. And then what you'll see, for example, I do have a patient who, when she first came to me, her blood pressure was 170 over 100, her A1C was greater than 14, she was about 80 pounds overweight, her two year kidney failure risk equation was 5%, her five year kidney failure risk equation was 14%. 

I saw her just last week. Her blood pressure has been perfectly controlled for the last two years, her A1C has been 6.5 or 6.7 for the last two years. And her new two year and five year kidney failure risk equation is 0.2 percent for two years and 0.7 percent at five years. That's what's possible. 

And so I think in terms of scaling it across the health system, you have to illustrate the art of what's possible. And then you really have to understand the difference between what are sequential care processes and what are iterative care processes. And how do you sort of blend those two together across a population to achieve clinical excellence? 

[00:20:00] Stacey Richter: Okay. Definitely want to dig into how to create care processes that are sequential and then ones that are iterative, which I'm assuming will depend on where it's at with the patient and maybe how much that patient trusts their clinical team. Let me just take one step back for a sec, though, because I really want to make sure I'm totally clear on a really foundational point here. 

Bob Matthews was on the podcast a couple of years ago, and one of the things that he was talking about is that the absence of care standardization.  

Achieving Organizational Excellence in Healthcare

[00:20:31] Stacey Richter: Using best practices of care in any sort of consistent organizational way, if you don't do that, the most you'll achieve is like, you'll get to 70 percent of whatever you're striving for because you're going to have great doctors doing amazing work, and then you're going to have not great doctors or not great clinicians not doing amazing work and it's going to average out so you're going to get 70 percent. It’s easy to say let's get trust with all of our patients and you're going to have great clinicians who are able to do that but that does not achieving organizational excellence make.  

So when you talk about illustrating the art of what is possible, does that mean basically saying, look, this is what's achievable and then relying on, like Dr. Marty Makary was on the pod, this is several years ago now, basically saying doctors are very competitive. So if you basically show them what their peers are doing, they'll level up. 

Is that what you're talking about or is there something that's more, what else is going on there?  

[00:21:31] Kenny Cole: No, I think that's exactly it. I think that's right because in, in fact, I'm glad you mentioned Bob Matthews. I mean, he was really one of the ones who's kind of started me on my own journey because the first time I heard him, I had just become chairman of medicine for a large multispecialty group. 

And so I challenged our group. The idea was that we should be able to achieve greater than 80 percent rate of control across a population. I actually made the mistake when I first presented it to the group that Kaiser in California had a 84 percent rate of control across 600,000 people, to which of course they quickly told me, well, of course it's California. 

They're skinny. They eat right. How can you compare, you know, California to Louisiana here? I mean, with our, the salt in our diet and our obesity, I mean, there's no way we could ever achieve that. But yet when we actually measured the results, what we had was a 60 percent rate of hypertension control, which at the time they thought was probably the best we were going to get in a state like Louisiana. 

But when you really look at the numbers, when we looked at the numbers around where did that 60 percent come from? It came from the fact that we already had some physicians who were 80 percent rate of control and we had other physicians that were 40 percent rate of control. And so, you know, we realized that 80 percent is possible and then the improvement phase is building out your clinical pathway and as more and more doctors start to adopt the clinical pathway and use it. 

It was, I think, about five years later where that multispecialty clinic won the award among mid sized groups as having the top rate of hypertension control in the country. Part of it is leadership. It's showing what's possible. Part of it is transparency. And yes, I do think all doctors at heart want to do what's right. 

It's just that when you're not measuring and holding yourself accountable for outcomes and really doing an in depth analysis of the data to understand where the improvement opportunities lie. You get these kind of false suppositions that are things like, well, of course, we're not going to be able to get greater than 80 percent rate of control. 

Not with our population, right? Our patients are sicker than the rest of the country, which of course that's a standard reply for many doctors when confront them about their own data is their patients are sicker. And so you have to overcome those barriers with physicians the same way you need to overcome obstacles, barriers, and challenges with patients. 

You just need to discover what they are. And then address them and move forward.  

[00:23:52] Stacey Richter: You're beginning this whole thing with illustrate what's possible. And I'm reminded of the whole thing with Roger Bannister. Everybody thought the four minute mile could not be beaten. So it wasn't. And then all of a sudden Roger Bannister beat the four minute mile. He ran faster than a four minute mile. 

The second that he did that and showed that it was possible, like the record was broken in six weeks or something like that. There's so much power in just showing what's possible. How you articulated that was that you showed that even in the state of Louisiana, with all of the issues that you talked about, you had some doctors achieving 80 percent blood pressure control and then others that were only achieving 40%. 

So like all of a sudden you show what's possible to them and you create a higher bar that everybody then was going to try to strive to live up to because they realize that it is in fact possible. It's worth throwing your back into it. You can do it. Somebody else is doing it. So also a little bit of competitive spirit there, but all of that lies on a foundation of you have to be measuring what you're doing. 

This was a big part of the conversation with Rik Renard from a couple of weeks ago. If anybody wants to go back and listen to that show, because we talk at length about how good a job digital health solutions are doing measuring performance metrics such as clinician and patient reported outcomes, financial performance, and then also patient satisfaction. Those four things.

And the point that Rik made and very clearly is that if you aren't measuring the results of your work, then you cannot improve. It's like if the problem is a black box, then so is the solution. You cannot find best practice care though, because how would you even know? That there was a doc with 80 percent control and everybody should check out what he or she was doing and try to emulate it. 

But in sum, we've got to show what's possible. Everybody has to see it and believe it. And then number two, measure. And then number three, and probably not to be underrated estimated, Dr. Sanat Dixit said this on LinkedIn the other day. He said doctors don't caucus well, right? So like you have to have kind of a culture where everyone believes in this whole mission and is aligned, which I don't think could be underestimated. 

Reinventing the Business Model of Healthcare

[00:26:10] Kenny Cole: This actually does become one of the reasons why, for me, the care flows, the care pathways, I mean, all of that is simply part of what needs to be done in order to arrive at where we're really trying to end up, which is how do you actually reinvent the business model of health care such that you are achieving financial and economic viability by doing what's best for patients, meaning that you're keeping them out of the hospital, you're keeping them out of the emergency room, you're preventing them from having bypass surgery or stents, or you're preventing them from being on dialysis. And, unfortunately, in the traditional healthcare system, all of those things are revenue to the health systems. 

Now, I'm not trying to say that there's anything malicious going on, but the health systems have traditionally stuck by the logic of no margin, no mission, meaning that we have to achieve a certain amount of revenue in order to pay for the infrastructure that is capable of improving health and health outcomes. 

And so, big health systems will employ primary care physicians typically at a loss, the primary care docs will lose money and then those docs, their incomes will be subsidized by the stents and the bypass surgeries and all of the downstream revenue that comes from what is in essence a primary care design model that is designed through the fee for service lens. 

[00:27:34] Stacey Richter: This is something so underappreciated and just contributes to all the PCP burnout and so many other bad things, right? Like, that if I think like a health system, failing primary care is a great boon to business if all we care about is revenue. And Rob Andrews talked about this with respect to NICU stays for babies on episode 415. 

And he said super succinctly, hey, look, there's no hospital administrator on the planet who's trying to drive up NICU admissions. But at the same time, these admissions, just like visits to the cardiac cash lab, I mean, cardiac, cath lab are very profitable while doing really great maternal care or really great primary care is usually in the current fee for service FFS (fee for service) model that doesn't reward cognitive work. 

There's no money here from a health system standpoint to have great primary care. So I know if I'm going to assess PCP performance based on revenue, I'm not going to be tracking patient reported or clinical outcomes. So if I'm going to. assess PCP performance just based on revenue and not patient outcomes, what do performance metrics look like for a lot of PCPs at some of these, in air quotes, more traditional fee for service organizations?  

[00:28:53] Kenny Cole: Performance metrics are going to be things like RVUs and panel sizes and all of these variables that are associated with the financial outcomes.  

[00:29:02] Stacey Richter: RVUs, relative value units, basically meaning good looks like lots of referrals for expensive services. 

[00:29:09] Kenny Cole: One of my favorite quotes in all of this is a quote from Upton Sinclair who says it's impossible for someone to understand something if their income depends on understanding the opposite. I do believe there are some probably health system payer executives and large health system executives where that sort of holds true, right? 

And sympathizing with the health system executives, they've got a tough road because they've got to figure out how to balance their feet in one of two canoes and keep themselves afloat without falling in the water as they kind of crank up the value driven model of primary care while actually having to still pay for all the fixed cost of the traditional model of volume driven primary care. 

[00:29:46] Stacey Richter: And now looping back to the very beginning of our conversation where you said that it doesn't matter where you are in the care transformation journey. Having care flows, determining whether, also you said this, are these care flows sequential or iterative, like really thinking through all of that, you could do that in a fee for service environment. 

Dr. Scott Conard was on the show talking about how even in a fee for service environment, he did in fact improve primary care results and he had a number of suggestions for how to do that. But even he ran up against the barrier that you're talking about. At a certain point, you wind up having perverse incentives that will undermine you. 

In the case of Dr. Scott Conard, which is a really interesting podcast. If anyone didn't listen to it, I would encourage you to go back. Here he was reducing hospital admissions, and you know what the local hospital did? They bought him and closed him down. Spoiler alert. One of the things that you said was super interesting, especially given the number of employers that listen to the show, where everyone's like, oh my gosh, that's how much a stent costs. 

That's how much a knee replacement costs. It's just highly pricey. But what you're basically saying, and I hear this all the time from other hospital financial folks too, is that, okay, yeah, except all of those really high priced services are subsidizing the areas that are losing money, such as I guess, primary care. 

So to keep primary care afloat, they really have to do all these referrals and order lots of MRIs or whatever, otherwise there's financial difficulties.  

The Role of Care Flows in Clinical Excellence

[00:31:18] Stacey Richter: And then at the same time, when you were talking about this, I'm thinking to myself, this seems like a long patient visit. When you were talking about the metformin example, it's a long patient interaction, like how long would it take to go through all the stuff that you were talking about and create that trust with this patient? 

If I've got 7 minutes or 15 minutes with the patient, this would be very difficult to achieve. And if all I'm really trying to do is crank out RVUs and as a PCP, I'm still trying to hit my 8,000 RVUs or whatever the heck it is per year, I just can't even do these things because just the whole model of care is set up against me. 

So I could see in these situations, I could see how the messy meadow would be a really difficult place.  

[00:32:00] Kenny Cole: Yeah, it really is, but even so, let's think about it even in a fee for service lens. And I'll never forget back when I was in practice at that multispecialty group, one of my partners who was Alpha Omega Honor Medical Society finished near the top of his medical school class. 

There was no doubt this physician was a really good doctor. One of his patients happened to end up on my schedule and they were on, gosh, 25, 30 different medications. Their blood pressure was really high. If you don't have an organized way of how you're going to approach that patient, it's going to take you a long time to sort through and it'll make for a much longer visit. 

But what I, at that point, I had a hypertension algorithm burned into my head. So I'm going down this list of medications. First thing I'm doing is I'm looking for either an ACE inhibitor or an angiotensin receptor blocker, and find that and then I go down and I find that the patient was actually on two different diuretics, probably didn't need to be on two different diuretics and so, okay, there's some room for thinking through this. So for me, it's I'm looking for a receptor blocker, then I'm looking for a calcium channel blocker, probably amlodipine. Next I might be looking for a thiazide diuretic, this was before a trial that just got published in December of 2021. But then this is how the beauty of these algorithms in these care pathways, as new data becomes available, you just modify the care pathway. 

You do that and you do that for everyone. It ends up being this wonderful, simplistic way of approaching care, but like going back to that patient who I saw from my partner, it made it such a quicker, easier visit because I was able to just go through in a very quick, sequential manner, quickly jettison a few medications, add another one, get them on the right hypertension path, and low and behold, we get the blood pressure controlled. 

That's the beauty of care flows. It speeds up clinical processing and decision making and thinking. And then ultimately where it's going to go is anytime you can turn something into an algorithm you can indeed digitize it and then you can create digital workflows that sort of take some of that work off of the physician, which is going to be necessary because there aren't enough hours in the day for primary care physicians to do all the things they need to do for a panel of say 2500 to 3000 patients.  

[00:34:22] Stacey Richter: I was thinking as you were talking, so just my takeaways from what you just said, that if you have care flows, then it takes a lot of cognitive burden off of the clinician in that moment, right? You know that, and again, there's a difference between good care flows that are based on evidence and ones that are not. 

But if you have a good care flow, then a lot of the cognitive burden is lifted off of the clinician in that moment so that you can use the time to create trust with the patient or do the important work of connecting with the patient. So, that would be really important. The other thing with the care flow, it's going to enable the clinician to work with the rest of the team, i.e. to make sure that patient actually shows up for the follow up visit. There's a lot of other things that can happen that spiral around that clinical visit, which we didn't really talk about today, but are obviously very important for anyone who's spent 10 minutes trying to do this. So, I, I think what we keep coming back to, both the science and the art of medicine are really important and have to be present and accounted for, and standardizing care flows well, and making sure that we've illustrated what is possible and there's a culture in the organization of trying to achieve it. 

All of these are essential ingredients to make sure that the level of care is consistent across the organization and as high as it possibly can be. Is there anything that you want to add to this conversation, Dr. Kenny Cole, that we did not have a chance to chat about?  

[00:35:54] Kenny Cole: I'll add just very briefly, no detail is too small. 

For example, in something that you just said, a care flow is not just receptor blocker and an ACE inhibitor and then next you add amlodipine and then next you add a thiazide diuretic. A care flow can also include the simple matter of you schedule the patient to come back to get their blood pressure checked in a few weeks, but if that patient doesn't show up, if they don't come back, well that's a huge gap in your care flow. 

Your care flow needs to ensure that they come back and so the way that I first did this the very first time I created something was in the electronic medical record we were using there was a little button called remind me. So literally I would go up and just click remind me blood pressure check in two weeks or blood pressure check in four weeks. 

If the patient came back in four weeks, we would delete the reminder. But if the patient didn't come back, you would put in a date and their name would essentially turn red. And if their name turned red, then that just executes a workflow for the nurse to call them and make sure that they're coming. So care flows are very detail oriented. 

And that you're trying to discover any variable in the, along the way of designing it that could potentially lead to a failure to achieve the control that you're trying to achieve. And you can do this for blood pressure, for diabetes, for hyperlipidemia, for, you can do it for any one of them. And when you do it well for all of them, right, because for me, it's not about having 95 percent rate of hypertension control or 95 percent diabetes control. 

It's about having 95 to 100 percent hypertension control and 95 to 100 percent diabetes control and 95 to 100 percent of my patients who have known vascular disease having their LDL less than 70 and that they're not smoking cigarettes and if they have known vascular disease that they're on secondary prevention with antiplatelet therapy. 

It's getting all of those "ands" and when you get all of those "ands" concomitantly, like the percentage that I'm going to want to measure my doctors and my redesigned care models is a bundled metric of how often are they getting all of those things right. What is that percentage? That's the percentage we're going to try to optimize because if we do, that's when we're truly going to impact the downstream poor health outcomes of strokes, heart attacks, etc. 

And ultimately that's going to be the goal is when we can measure and hold ourselves accountable for how few heart attacks or how few strokes or how few of our patients are progressing through the stages of chronic kidney disease to end stage kidney disease. Once we get to that ideal percentage, that's when we will have achieved what is truly the art of the possible. 

Conclusion and Further Resources

[00:38:32] Stacey Richter: That is very inspiring. Dr. Kenny Cole, if people are interested in learning more about your work, where would you direct them?  

[00:38:39] Kenny Cole: I write in these journal articles. It's nothing prestigious. It's a local healthcare journal. I've written about 11 different articles in that local healthcare journal, and a lot of that has many of the things that we've spoken about. 

[00:38:49] Stacey Richter: We will link to them in the show notes. Dr. Kenny Cole, thank you so much for being on Relentless Health Value today.  

[00:38:56] Kenny Cole: Thank you. It was a pleasure being with you.  

[00:38:57] Stacey Richter: So let's talk about going over to our website and typing your email address in the box to get the weekly email about the show that has come out. 

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