Introduction and Episode Overview
[00:00:00] Stacey Richter: Episode 473, Take Two. This time, listen for how trusted relationships and excellent primary care teams keep patients out of the ER and other high cost care settings. Plan sponsors, taxpayers, hi, this is extremely relevant. Today I speak with Dr. Kenny Cole.
The Importance of Trusted Relationships in Primary Care
[00:00:37] Stacey Richter: I'm revisiting in a Take Two this episode with Dr. Kenny Cole because I'm listening to it this time with a new focus. That focus is the theme that keeps coming up over and over and over again on Relentless Health Value these past few months.
To listen to this episode or read the show notes with all mentioned links, visit the episode page.
If primary care teams do not have, among other things, but if care teams or somebody on the care team doesn't build a trusted relationship with plan members/patients, then in a moment that really matters, the patient/member will suboptimally wind up in the ER.
And if this happens across an entire plan, sponsors member population, all these pilgrimages to the ER, it comes at great cost to the patient, the plan and society really, both clinically and financially. ER spend these days is about 6% of average plan spend. That's nuts. 6%.
And this is why, as Denise Wiseman wrote the other day on LinkedIn, and I loved how she put it. She said, "Primary care is absolutely an investment in health and wellness, not a cost. Trust is the foundation without trusted relationships between patients and care teams. We're not investing, we're just reacting. And as you Stacey Richter", that's me, "and others have pointed out, we are reacting in the most expensive setting possible: The ER".
So thanks for writing that, Denise.
Challenges and Perverse Incentives in Healthcare
[00:01:56] Stacey Richter: But this whole concept, a trusted relationship with a primary care team. It could feel soft and squishy, and it is so easy for someone looking at a spreadsheet to cross off as wasted spend or wasted time and time is money. So cross off the things that it will take to build these relationships. Either this, or good primary care falls victim to the very, very real perverse incentives to drive commercial ER volume or volume to high revenue service lines. Just stating facts. It's logical.
Listen to the show with Dr. Vivian Ho about some of the perverse financial incentives in play here for hospitals. One with Dr. Scott Conard and the show with Al Lewis. There's a bunch of adjacent points. So, yeah, let's consider this conversation with Dr. Kenny Cole today through the lens actually of what is required so that primary care can live up to its potential to be an investment in the real world.
And that means recognizing what it actually takes to deliver great primary care. Trust being a piece of this. Yeah, I'm gonna echo what Matt McQuide said. If you aren't getting your members a trusted advisor, who will be there for them when it matters and when there's important decisions being made about where to go for something big, someone else is gonna steer that member and they're steering based on their own financial incentives and interests. Dr. Kenny Cole is from Ochsner Health System, and I loved this conversation. I loved it the first time and I loved it the second time because it has lessons for plan sponsors on what to look for, that's for sure.
But it also will speak to anybody working in a clinic or managing a clinic or who wants to learn from a master. This show is also very intriguing for anybody who's trying to work with or for a clinical practice or a health system that is pulling away from the status quo. One that is earning the trust of its patients.
And also one that is figuring out how to reinvent the business model such that the best practice clinical pathways and care flows are aligned with financial viability. That's really the holy grail there.
We talk about how to achieve this clinical and financial success, even if the financial models are all over the map, which they so often are.
Conversation with Dr. Kenny Cole: Key Points and Insights
[00:04:06] Stacey Richter: The show today sums up four main points by my counting, and they are as follows. I'm just gonna recap them here, but Dr. Kenny Cole gets into them from a level of deep personal understanding, so please do listen to the show.
The four points are: clinical teams have to deliver care in such a way that those clinical teams are accountable for the outcomes that are generated. That's number one.
Number two, clinical teams need to really see with their own two eyes and believe that a clinical goal that has been set 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.
Number four, the theme that keeps coming up 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.
There are a whole bunch of shows besides even what I already mentioned that are relevant and adjacent to this one. I am going to put a long list of them in the show notes where you can also find a transcription of everything I just said.
Dr. Kenny Cole, as I mentioned, works at Ochsner. He is a primary care internist. He sees patients one day a week, and the other days serves as a system vice president. In this role, he designs and develops new care models.
Sponsor Acknowledgements and Listener Engagement
[00:05:27] Stacey Richter: New topic for just a sec. What always warms my heart is when it comes to you listening. There's so much that is wonderful about this Relentless Tribe of ours.
To that end, I wanted to share with you that I got a call recently from Kelly Paul from Idaho. Kelly said that she wants to sponsor an episode because she wants to contribute to Relentless Health Value. She says she listens all the time and just wanted to give back. Let me tell you, it's people like Kelly who keep me motivated here.
I had a chance to meet Kelly and I learned a lot, and this is not her day job, but she has a small business. So on the side, she makes functional accessories for cochlear implants for kids and adults to help keep their devices in place. And as soon as I heard that, of course I wanted to mention it, even if it's just to honor a small business owner solving a problem that needs to be solved.
I mean, it's hard enough to have a kid, it's hard enough to deal with deafness and also have an expensive device that could easily go missing.
Kelly's website is ciretentionsolutions.com. So check it out if you have a need. Support Kelly, and thanks so much to Kelly for sponsoring the show with Dr. Kenny Cole.
Oh, also, hey you lot you tribe. Did you know that the last time that we got a review on Apple Podcasts was last October? Do you believe that? It was an amazing review. Don't get me wrong, it starts "Why this New York City nurse trusts Relentless Health Value", from the one and only Michelle Bernabe, who I think from the bottom of my heart and I could not have appreciated it more.
Read a great post by Michelle Bernabe on how we can get the heart back into healthcare link in the show notes.
But yeah, if you have not yet written a review, please give me a shout out. There's instructions for how to do this on the website. It does really matter, and if you take the time to do it, please know you rock.
And with that, here is my conversation with Dr. Kenny Cole.
This podcast is sponsored by, as I just said, Kelly Paul, thank you so much. And also by Aventria Health Group.
Interview with Dr. Kenny Cole: Clinical Excellence and Patient Trust
[00:07:24] Stacey Richter: Dr. Kenny Cole, welcome to Relentless Health Value.
[00:07:26] Kenny Cole: Thank you for having me. Nice to be here.
[00:07:28] Stacey Richter: I'm trying to figure out how to kick off this interview to make a really strong point. That 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.
[00:07:46] Kenny Cole: Yeah. Let's just take that example of metformin. You're not gonna find any disagreement among clinicians that metformin should be the foundation of pharmacotherapy for the treatment of type two diabetes.
But where you are gonna find lots of clinically unwarranted practice pattern variation 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 gonna get the GI side effects. And so I, for example, I would have a smart phrase 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, 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, 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%.
[00:09:35] Stacey Richter: 98 or 99% 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 obviously they weren't 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 overcome-able. If that's a word.
[00:10:06] 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.
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 co-produce a desired health outcome preferentially one that matters most to the patient themselves. So that we're appealing to their intrinsic source of motivation.
[00:10:53] Stacey Richter: What you're saying is it very aligns with the conversation that I had actually with Dr. Robert Pearl 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 co-produce with you.
[00:11:26] Kenny Cole: That's right. I am and want to be held fully accountable for the outcomes that I am co-producing with 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.
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 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.
[00:12:32] 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 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. And we had a conversation about this before, actually, you and I, and you said, let's begin with the end in mind.
[00:13:05] Kenny Cole: You do start with the end in mind and, and so that is gonna 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 stroke or who wants to have heart failure because they spent years of with uncontrolled hypertension.
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, if the greatest love of their life is fishing, you've gotta be able to have good sensation to be able to feel that line when a fish bites. 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 be for you to be able to fish for as many years as possible. And to do that, we've gotta prevent the numbness that's gonna come in your fingers and your feet. And in order to do that, we're gonna have to control your sugar.
And what that control of your sugar looks like is gonna be an A1C of seven, and that's gonna be the measure that we're gonna 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 up from there to then begin with what the care flow looks like from the beginning.
[00:14:28] 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% blood pressure control is what the standard should be, which is gonna blow some people's minds right now because across the rest of the country, if, if blood pressure is 70, 75% controlled, people think they're doing amazing work.
So we have the 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. Like, 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 gonna 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 “they don't wanna scare the patient.”
Scaling Clinical Excellence and Overcoming Barriers
[00:15:41] Stacey Richter: So like I'm trying to figure out how do you scale clinical excellence?
[00:15:48] Kenny Cole: The first thing is you show it can be done like you show what is the new standard of care. What should be acceptable because yes, I do believe that the future standard of care will be that anything less than 90 to 95% rates of diabetes control is gonna be considered substandard.
Anything less than probably 95% rate of hypertension control is gonna 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 gonna let them know that I only have one goal and my one and only goal is to earn their trust.
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 and you might even want to calculate their kidney failure risk equation, both a two year and five year risk.
You can let 'em know what the percentage looks like. Then you can let 'em 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 them and that you're gonna do it together, and that here's how we're gonna 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 two year kidney failure risk equation was 5%. Her five year kidney factor risk equation was 14%.
I saw her just last week. Her blood pressure's been perfectly controlled for the last two years. Her A1C has been 6.5 or 6.7 and her new two year and five year kidney failure risk equation is 0.2% for two years and 0.7% at five years. That's what's possible. And so I think in terms of scaling it across a health system, you have to illustrate the art of what's possible.
And then you really have to understand the difference between what are our 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?
The Role of Care Flows and Standardization
[00:18:06] Stacey Richter: Okay. Definitely wanna dig into how to create care processes. Let me just take one step back for a sec.
I really wanna 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, 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% of whatever you're striving for because you're gonna have great doctors doing amazing work, and then you're gonna have not great doctors or not great clinicians not doing amazing work, and it's gonna average out, so you're going to get 70%.
It's easy to say, let's get trust with all of our patients, and you're gonna 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?
[00:19:22] Kenny Cole: Well, I think that's exactly it. I'm glad you mentioned Bob Matthews. He was really one of the ones who's kind of started me on my own journey. The first time I heard him, I had just become chairman of medicine for a a large multispecialty group. And so I challenged our group to achieve greater than an 80% rate of control.
I actually made the mistake when I first presented it that Kaiser in California had a 84% 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's, Louisiana here. I mean, with the salt in our diet and our obesity, there's no way we could ever achieve that.
But yet when we actually measured the results, what we had was a 60% rate of hypertension control, which at the time they thought was probably the best we were gonna get in a state like Louisiana.
When we looked at where did that 60% come from, it came from the fact that we already had some physicians who were 80% rate of control, and we had other physicians that were 40% rate of control. We realized that 80% 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-size 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 gonna be able to get greater than 80% 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, address 'em, and move forward.
[00:21:29] Stacey Richter: You're beginning this whole thing with illustrate what's possible and I'm kind of reminded of the whole thing with Roger Banister.
Everybody thought the four minute mile could not be beaten. So it wasn't, and then all of a sudden Roger Banister 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, I think, 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% 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 they realized is in fact possible. It's worth throwing your back into it. You, 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. If anybody wants to go back and listen to that show and the point that Rik made. If you aren't measuring the results of your work, then you cannot improve. You cannot find best practice care because how would you even know that there was a doc with 80% control and everybody should check out what he or she was doing and try to emulate it.
In sum, we've gotta show what's possible. Like everybody has to see it and believe it. And then number two, measure. And then number three, and probably not to be underestimated, Dr. Sanat Dixit said this on LinkedIn, he said, doctors don't caucus as well, right? So like you have to have kind of a culture where everyone believes in this whole mission.
[00:23:18] Kenny Cole: For me, the care flows, the care pathways, I mean, all of that. Is simply part of what needs to be done to arrive where we're really trying to end up, which is how do you actually reinvent the business model of healthcare 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, 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.
[00:24:39] Stacey Richter: Insert from the future, and here we go. The theme of how undermining good primary care looks very good on paper sometimes only in the short term, though, mind you, for some health system leadership teams. Listen to the show with Dr. Vivian Ho. As I mentioned in the intro.
And I'm saying this without judgment, I'm saying this as a fact. This is happening across the country and plan sponsors especially, just really need to be aware of this because, yeah. Besides the show with Dr. Vivian Ho, that I just mentioned, also listen to the one show with Rob Andrews that I mention in about two seconds, which reiterates really everything I just said about incentives.
This is something so under appreciated 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, are very profitable while doing really great maternal care, or really great primary care is usually in the current fee for service, FFS model that doesn't reward cognitive work. Like there's no money here from a health system standpoint to have great primary care.
[00:26:00] 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 as they kind of crank up the value driven model of primary care while having to still pay for all the fixed cost of the traditional model of volume driven primary care.
[00:26:30] Stacey Richter: And now looping back to the very beginning of our conversation where you said it doesn't matter where you are in the care transformation journey, having care flows, determining whether also you said, 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. Then at the same time, I'm thinking to myself 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 seven minutes or 15 minutes with the patient, this would be very difficult to achieve. And if 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.
[00:27:53] 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 multi-specialty 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 gonna take you a long time to sort through and it'll make for a much longer visit.
But what I, at that point, you know, 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. You know, and like I, I 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 an, an ACE inhibitor or an angiotensin 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, and this is how the beauty of these algorithms in these care pathways. As new data becomes available, you just modify the care pathway and 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 lo 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 gonna 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 gonna 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, 2,500 or 3,000 patients.
[00:30:14] Stacey Richter: I talked with Dr. Beau Raymond on a show about how Ochsner is starting to digitize are pathways. Just to underline with six colors, the point that we know how to deliver amazing primary care. We know it.
It's just like Dave Chase always says, healthcare is already fixed. We know how to transform healthcare. There are solutions available. We just have to get those solutions adopted broadly. And this is a perfect example of this.
I was thinking as you were talking, so just my takeaways from what you just said.
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 or do the important work of connecting with the patient. The other thing with the care flow, it's going to enable the clinician to work with the rest of the team ie, 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.
I think what we keep kind of coming back to both the science and the art of medicine are really important and have to be present and accounted for.
[00:31:30] Stacey Richter: 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.
Conclusion and Final Thoughts
[00:31:49] Stacey Richter: Dr. Kenny Cole, is there anything that you wanna add to this conversation.
[00:31:53] 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, you start with an angiotensin 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. And 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 'em and make sure that they're coming back.
So care flows are very detail oriented and that you're trying to discover any variable that could potentially lead to a failure to achieve the control that you're trying to achieve. You can do this for blood pressure, for diabetes, for hyperlipidemia, for you can do it for any one of 'em. And when you do it well for all of them, right?
Because for me it's not about having 95% rate of hypertension control or 95% diabetes control. It's about having 95 to a hundred percent hypertension control and 95 to a hundred percent diabetes control, and 95 to a hundred 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 gonna wanna measure my doctors and my redesign 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 gonna try to optimize because if we do, that's when we're truly gonna impact the downstream poor health outcomes of strokes, heart attacks, end stage kidney disease, etc.
Once we get to that ideal percentage, that's when we will have achieved what is truly the art of the possible.
[00:34:15] Stacey Richter: That is very inspiring. Dr. Kenny Cole, if people are interested in learning more about your work, where would you direct them?
[00:34:22] 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.
[00:34:32] 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.
[00:34:39] Kenny Cole: Thank you. It was a pleasure being with you.
[00:34:40] Matt McQuide: Hey, this is Matt McQuide with Synergy Healthcare. I listen to Stacey and Relentless Health Value every single week. There's valuable information every single week to take from it, and I just so appreciate this is around.