EP431: How Accountability for Outcomes Works in the Real World With Kenny Cole, MD

[00:00:00] Episode 431 How Accountsability for Outcomes Works in the Real World Today I Speak with Dr. Kenny Cole

[00:00:30] from the Interwebs with the caption, sometimes the shortest distance in between two places isn't a straight line.

[00:00:37] What? Yeah, because actually there's three dimensions in the real world see the link in the show notes.

[00:00:44] 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.

[00:00:53] Not only if you're timing rubber balls getting dropped off straight or curved slopes.

[00:00:58] 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.

[00:01:12] And then the plan ultimately fails. What contours am I talking about taking into account right now?

[00:01:18] Oh, pretty much the entirety of US health care. If you combine the complexities and perverse incentives of the industry itself plus the art and science of medicine plus epitomology and social determinants and I'm probably forgetting other dimensions, you have contours that are mountain ranges.

[00:01:35] 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.

[00:01:43] Now investors and C-sweets may like these delusions, but let's just get real. It's not going to actually work out as written.

[00:01:51] One case study that I am talking about is digital health solutions or pharma companies even are pretty much anyone who thinks that the fastest way to increase sales is to talk about the product.

[00:02:01] Let's just say his one example. That's the straight line to growth. Talk about the product.

[00:02:05] 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.

[00:02:15] I talk about this at length with Kate Wollin in an episode coming up.

[00:02:19] Jodelyn Owen has a thing or two to say on this point in episode 421 also, but let me be clear.

[00:02:26] I'm not talking about anyone listening to the show today, making this mistake at least wholesale.

[00:02:33] We all make it incrementally. It's hard to avoid, but you get this. That's why you're here.

[00:02:38] 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.

[00:02:50] No one cares how efficient or safe your thing is if it's accomplishing something that no one cares about.

[00:02:56] 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 Walksman was about.

[00:03:07] Why is all of this relevant? It's actually what makes relentless health value relevant.

[00:03:12] Frankly, many listeners and shout outs to Blake Walker and Mary Carol Evans.

[00:03:18] 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.

[00:03:30] And on the show today, Dr. Kenny Cole I got to say could be really impactful in this regard as well as in others.

[00:03:38] Dr. Kenny Cole is from Ashner 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.

[00:03:49] 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.

[00:04:02] 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.

[00:04:17] 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.

[00:04:27] 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.

[00:04:42] This episode reminded me a lot of the conversations with Dr. Scott Canard. There's lots of complimentary points. The shows with Dr. David Carmoush from when he was at Ashner is also pretty relevant here.

[00:04:54] Some of the points that Dr. Kenny Cole makes today also align very much with what Rick Renard was talking about a few weeks ago.

[00:05:01] But regardless of where you sit or what you're trying to do, the show is a great one to really get a beat on the lay of the land to find the actual shortest path between here and there which is not going to be most likely and obviously straight line.

[00:05:17] 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 where an 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.

[00:05:43] 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.

[00:05:55] And number four last point building trust with patients and connecting with patients cannot be underestimated and care flows needs to not only standardize care so that it can be delivered quicker and easier but also facilitate patient relationships.

[00:06:11] 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 austenar 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.

[00:06:33] Oh two last things and new topics first thanks to Santos Al Halpert Nina Latia and Kc64789 for some really nice reviews this month I read them they make me happy thanks so much for leaving them.

[00:06:49] And lastly heads up that rule of three has an annual March health care 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

[00:07:02] trends will reign supreme in their impact on health care in 2024 the committee includes Dr. David Carmouche from Walmart Eric Gallagher from Osnar Health Network Leah Binder who is the CEO of leapfrog and Anisha snued from first choice health so check it out my name is Stacy Richter this podcast is sponsored by a Venturia health group.

[00:07:28] Dr Kenny Cole welcome to relentless health by you thank you for having me nice to be here 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

[00:07:45] 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.

[00:08:06] 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 form a co therapy for the treatment of type 2 diabetes but where you are going to 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.

[00:08:33] 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.

[00:08:47] 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.

[00:09:09] That's when they're going to 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.

[00:09:19] I wrote it myself like you have 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 inner even 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.

[00:09:38] 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% as you were talking i'm thinking about a couple of different things one of them is that 98 or 99% of patients on metformin, which is a gold standard here as you said is that the patient is not a good person.

[00:10:07] As you said is amazing many patients can't take metformins due to these GI side effects and then they winds 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.

[00:10:27] 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.

[00:10:39] 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.

[00:10:57] 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 non compliant where we basically label a patient as non compliant because they failed to do what we told them to do.

[00:11:14] And I don't really like non adherent any better it's a slightly kinder gentler version of non compliant it's not about them complying our hearing to what we tell them to do it's about how effective our work.

[00:11:26] 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.

[00:11:45] What you're saying is very aligned 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 mold over it actually for I'm still mold 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 the pull.

[00:12:15] 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.

[00:12:34] What the patient wishes to co produce with you that's right for example I still do see patients one day week and I am and want to be held.

[00:12:45] I'm told fully accountable for the outcomes that I am co producing 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

[00:13:14] that you prescribe them because there neighbors 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.

[00:13:30] 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 trust the science because they trust you the doctor.

[00:13:50] 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

[00:14:08] 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.

[00:14:18] And we had a conversation about this before actually you and I and you said let's begin with the end in mind.

[00:14:24] 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

[00:14:36] a part of the patient who is not able to be a part of the patient or who wants to have a health failure because they spent years of with uncontrolled hypertension what we have failed to do thus for in health care is even really define what health is for example sticking with the theme of diabetes for a moment somebody who's the greatest love of their life is fishing and they know that basically fishing you've got to be

[00:15:06] 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 a once you 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

[00:15:26] 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

[00:15:43] and so fully interpret 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.

[00:15:51] Here's my big question I have a conundrum for you after goal because you're delivering clinical excellence to your patients I mean if you have 90 plus percent of your patients on metform 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 blood pressure

[00:16:12] and a 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.

[00:16:21] 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

[00:16:36] 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.

[00:16:44] It makes a ton of sense on the other hand you're going to talk to a lot of clinicians like Dr. John rotis is a medical director over at UC Health and we're doing a lot of stuff with kidney disease.

[00:16:55] 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.

[00:17:05] So like 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.

[00:17:24] The first thing is you show it can be done like you show what is the new standard of care.

[00:17:30] 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 was going to be considered

[00:17:41] standard anything less than probably 95% 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

[00:17:56] 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.

[00:18:04] 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 there I'll be going to

[00:18:22] you would calculate the kidney failure risk equation both a two year five year risk you can let them know what the percentage looks like.

[00:18:29] But then you can let them know that you're right there with them and that the goal is that we can reverse that we can actually buy better controlling blood pressure and buy better controlling diabetes and buy making sure that

[00:18:41] we're addressing the cardiovascular risk factors appropriately to reduce the risk of cardiovascular and adverse cardiovascular outcome because of course that is the leading cause of death even in chronic kidney disease.

[00:18:53] That you're right there with them 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 a one C was greater than 14.

[00:19:08] She was about 80 pounds overweight her two year kidney failure risk equation was 5% her five year kidney fact your risk equation was 14%.

[00:19:18] I saw her just last week her blood pressure has been perfectly controlled for the last two years or a one C has been 6.5 or 6.7 for the last two years and her new two year in five year kidney failure risk equation is 0.2% for two years and 0.7% at five years.

[00:19:35] 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 sequential care process and what are iterative care processes and how do you sort of blend those two together across a population to achieve clinical excellence.

[00:19:58] 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 trust their clinical team.

[00:20:14] 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.

[00:20:28] And then you're going to have a great understanding of the fact that you're going to have a great understanding of your 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 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

[00:20:58] and 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.

[00:21:10] Does that mean basically saying look this is what's achievable and then relying on like Dr. Marty McCarry was on the pod this several years ago now basically saying doctors are very competitive.

[00:21:21] 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.

[00:21:29] Well, I think that's exactly it. No, I think that's right because in fact I'm glad you mentioned Bob Matthews and 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 multi specialty group.

[00:21:44] And so I challenged our group the idea was that we should be able to achieve greater than 80% rate of control across a population.

[00:21:53] I actually made the mistake when I first presented it to the group 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 back and you've

[00:22:08] come to you know California is Louisiana here. I mean with our assault in our diet and our obesity. I mean there's no way we could ever achieve that.

[00:22:15] But yet when we actually measured the results what we had was a 60% rate of hypertension control which at the time they thought it 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% come from.

[00:22:34] It came from the fact that we already had some positions who were 80% rate of control and we had other positions that were 40% rate of control.

[00:22:42] And so you know we realize that 80% 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.

[00:22:53] It was I think about five years later where that multi specialty clinic won the award among midsize groups as having the top rate of hypertension control in the country.

[00:23:02] 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 it in depth analysis with the data to understand where the improvement opportunities lie.

[00:23:20] 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% rate of control not with our population right our patients are sicker then the rest of the country which of course that's that's a standard reply for many doctors.

[00:23:35] 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.

[00:23:47] And then address them and move forward 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.

[00:24:00] And then all of a sudden Roger banister beat the four minute mile like 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 I think in just showing what's possible.

[00:24:17] And 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.

[00:24:36] And then 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.

[00:24:59] So that's a big part of the conversation with Rick 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.

[00:25:19] And the point that Rick made and very clearly is that if you aren't measuring the results of your work, then you cannot improve it's like a if the problem is a black box.

[00:25:29] 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% control and everybody should check out what he or she was doing and try to emulate it but in some we've got to show what's possible like everybody has to see it and believe it.

[00:25:49] And then number two measure and the number three and probably not to be underestimated doctor sanate dixon said this on LinkedIn the other day he said doctors don't call as well.

[00:25:59] 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.

[00:26:08] This actually does become one of the reasons why for me the stair the care flows the care pathways 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

[00:26:36] you're keeping them out of the emergency room you're preventing them from having bypass surgery or stance are you're preventing them from being on dialysis and unfortunately in the traditional health care 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.

[00:27:06] 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 stance in 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.

[00:27:32] This is something so underappreciated and just contributes to all the PCP burn out in 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 Nick you stays for babies on episode 415 and he said super succinctly hey look there's no hospital administrator on the planet

[00:28:02] who's trying to drive up Nick you 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 really great primary care is usually in the current fee for service FFS model that doesn't reward cognitive work

[00:28:22] 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 gonna 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.

[00:28:50] Performance metrics are going to be things like RV use and panel sizes and all of these variables that are associated with the financial outcomes RV use relative value units basically meaning good looks like lots of referrals for expensive services.

[00:29:06] One of my favorite quotes and all this is a quote from up to Sinclair who says it's impossible for someone to understand something if their income depends on understanding the opposite I do believe there's some probably health system payer executives and large health system executives where that sort of holds true right in some pausing 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 you know and keep themselves afloat without falling in the water as they kind of cranking up.

[00:29:36] 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 and now looping back to the very beginning of our conversation where you said that doesn't matter where you are in the care transformation journey.

[00:29:54] 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 Knard 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 winds up having perverse

[00:30:23] incentives that will undermine you in the case of Dr. Scott Knard 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 priced but it's not a lot of money.

[00:30:53] But what you're basically saying and I hear this all the time from other hospital financial folks to 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

[00:31:16] and then at the same time when you were talking about this think into myself this seems like a long patient visit when you're 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

[00:31:39] really trying to do is crank out RV use and as a pzp I'm still trying to hit my 8000 RV use 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

[00:31:55] messy meadow would be a really difficult place 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

[00:32:06] I said that multispecial group one of my partners who was alfomega honor medical society finishing the top is medical school class there was no doubt this

[00:32:14] position 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

[00:32:24] 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 calm

[00:32:32] 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 as

[00:32:42] 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 find that

[00:32:50] 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

[00:32:57] diuretics and so okay there's some room for thinking through this so for me it's I'm looking for an ACE inhibitor or an

[00:33:04] angiotensin receptor blocker then I'm looking for a calcium channel blocker preferably I'm low to peen next I might be looking for a

[00:33:12] thiozide diuretic this was before a trial that just kept published in December of 2021 but and this is how the beauty

[00:33:18] of these algorithms in these care pathways there's new data becomes available you just modify the care pathway

[00:33:24] you do that and you do that for everyone it ends up being this wonderful simplistic way of approaching care

[00:33:32] but like going back to that patient who I saw from our partner it made it such a quicker easier visit because I was able

[00:33:38] to just go through in a very quick sequential manner quickly jettison a few medications add another one

[00:33:46] get them on the right hypertension path and low and behold we get the blood pressure controlled

[00:33:51] that's the beauty of care flows it speeds up clinical processing and decision making and thinking

[00:33:59] and then ultimately where it's going to go is anytime you can turn something into an algorithm you

[00:34:04] can indeed digitize it and then you can create digital workflows that sort of take some of that work

[00:34:09] off of the physician which is going to be necessary because there aren't enough hours in the day

[00:34:14] for primary care positions to do all the things they need to do for a panel of say 2500 or 3000 patients

[00:34:20] I was thinking as you were talking so just my takeaways from what you just said that if you have care flows

[00:34:26] then it takes a lot of cognitive burden off of the clinician in that moment right you know that

[00:34:32] and again there's a difference between good care flows that are based on evidence

[00:34:37] and ones that are not but if you have a good care flow then a lot of the cognitive burden is lifted

[00:34:43] off of the clinician in that moment so that you can use the time to create trust with the patient or

[00:34:50] do the important work of connecting with the patient so that would be really important the other

[00:34:56] thing with the care flow it's going to enable the clinician to work with the rest of the team i.e.

[00:35:03] to make sure that patient actually shows up for the follow-up visit there's a lot of other things

[00:35:08] that can happen that spiral around that clinical visit which we didn't really talk about today but

[00:35:13] are obviously very important for anyone who's spent 10 minutes trying to do this so I think what we

[00:35:20] keep kind of coming back to both the science and the art of medicine are really important and have

[00:35:25] to be present and accounted for and standardizing care flows well and making sure that we've illustrated

[00:35:32] what is possible and there's a culture in the organization of trying to achieve it all of these

[00:35:37] are essential ingredients to make sure that the level of care is consistent across the organization

[00:35:44] and as high as it possibly can be. Is there anything that you want to add to this conversation

[00:35:49] doctor Kenny Cole that we did not have a chance to chat about? I'll add just very briefly no detail

[00:35:54] is too small for example and something that you just said a care flow is not just you start with

[00:36:01] an anxious receptor blocker and an asin inhibitor and then next you add and low to peen and then next

[00:36:05] you add a thizi diuretic. A care flow can also include the simple matter of you schedule the patient

[00:36:12] to come back to get their blood pressure checked in a few weeks but if that patient doesn't show up

[00:36:17] if they don't come back well that's a huge gap in your care flow your care flow needs to ensure

[00:36:23] that they come back and so the way that I first did this the very first time I created something was

[00:36:28] in the electronic medical record we were using there was a little button called remind me and so

[00:36:32] literally I would go up and just click remind me blood pressure check in two weeks or blood pressure

[00:36:37] check in four weeks if the patient came back in four weeks we would delete the reminder but if the

[00:36:43] patient didn't come back you would put in a date and their name would essentially turn red and if

[00:36:47] their name turned red then that just executes a workflow for the nurse to call them and make sure

[00:36:52] that they're coming so care flows are very detailed oriented and that you're trying to discover

[00:36:59] any variable in the along the way of designing it that could potentially lead to a failure to

[00:37:06] achieve the control that you're trying to achieve and you can do this for blood pressure for diabetes

[00:37:11] for hyperlipidemia for you can do it for any one of them and when you do it well for all of them

[00:37:18] right because for me it's not about having 95 percent rate of hypertension control or 95 percent

[00:37:23] diabetes control it's about having 95 to 100 percent hypertension control and 95 to 100 percent

[00:37:30] diabetes control and 95 to 100 percent of my patients who have known vascular disease having their LDL

[00:37:37] less than 70 and that they're not smoking cigarettes and if they have known vascular disease that

[00:37:43] their own secondary prevention with any platelet therapy it's getting all of those ants and when

[00:37:48] you get all of those ants can commonly like the percentage that I'm going to want to measure my

[00:37:52] doctors and my redesign care models is a bundled metric of how often are they getting all of those

[00:37:58] things right what is that percentage that's the percentage we're going to try to optimize because

[00:38:03] if we do that's when we're truly going to impact the downstream poor health outcomes of strokes

[00:38:09] heart attacks etc. and ultimately that's going to be the goal is when we can measure and hold

[00:38:14] ourselves accountable for how few heart attacks or how few strokes or how few of our patients are

[00:38:20] progressing through the stages of chronic kidney disease to end stage kidney disease once we get

[00:38:25] to that ideal percentage that's when we will have achieved what is truly the art of the possible

[00:38:30] that is very inspiring dr. Kenny call if people are interested in learning more about your work where

[00:38:35] would you direct them I write these journal articles it's nothing prestigious it's a local health

[00:38:40] care journal ever written about 11 different articles and that local healthcare journal and a lot

[00:38:45] of that has many of the things that we've spoken about we will link to them in the show notes dr.

[00:38:50] Kenny call thank you so much for being on relentless health value today thank you it was a

[00:38:54] pleasure being with you so let's talk about going over to our website and typing your email address

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