Standardized assessment, information, and networking technologies (SAINTs): lessons from three decades of development and testing.

PURPOSE: To rectify the significant mismatch observed between what matters to patients and what clinicians know, our research group developed a standardized assessment, information, and networking technology (SAINT). METHODS: Controlled trials and field tests involving more than 230,000 adults identified characteristics of a successful SAINT- www.HowsYourHealth.org -for primary care and community settings. RESULTS: Evidence supports SAINT effectiveness when the SAINT has a simple design that provides a service to patients and explicitly engages them in an information and communication network with their clinicians. This service orientation requires that an effective SAINT deliver easily interpretable patient reports that immediately guide provider actions. For example, our SAINT tracks patient-reported confidence that they can self-manage health problems, and providers can immediately act on patients' verbatim descriptions of what they want or need to become more health confident. This information also supports current and future resource planning, and thereby fulfills another characteristic of a successful SAINT: contributing to health care reliability. Lastly, SAINTs must manage or evade the "C-monsters," powerful obstacles to implementation that largely revolve around control and commercialism. Responses from more than 10,000 adult patients with diabetes illustrate how a successful SAINT offers a standard and expedient guide to managing each patient's concerns and adjusting health services to better meet the needs of any large patient population. CONCLUSION: Technologies that evolve to include the characteristics described here will deliver more effective tools for patients, providers, payers, and policymakers and give patients control over sharing their data with those who need it in real time.

Development of a care guidance index based on what matters to patients.

INTRODUCTION: Targeting resources for a designated higher-risk subgroup is a strategy for chronic care management. However, risk-designation has several limitations: it is inaccurate, seldom helpful for care guidance, and potentially misallocates care away from many patients. METHODS: To address limitations of risk designation, we tested a "what matters index" (WMI) in 19,593 adult patients with chronic conditions. The WMI contains five binary measures: insufficient confidence to manage health problems, level of pain, emotional problems, polypharmacy, and adverse medication effects. We examined its sum for association with patient-reported quality of life and prior emergency or hospital use. We compared its accuracy to a prototypic risk-designation model. RESULTS: The WMI was a good indicator for quality of life and in three diverse test populations it was strongly associated with the use of hospital and emergency services. For example, a sum of WMI ≥2 was associated with twice as many average uses as none; for ≥3, uses were three times higher. However, since relatively few patients use costly care, both the WMI and a prototypic risk-designation model had comparably low-positive predictive values. The WMI uses the patient voice to identify needs strongly associated with quality of life. Akin to risk designation models, the WMI can be used to place patients into groups associated with levels of costly services, but neither is likely to forecast costly service use for individuals. However, unlike risk-designation models, the WMI is based on measures that will immediately guide care for every patient.

A "What Matters Index" (WMI) for Adolescents.

A "What Matters Index" (WMI) represents the distillation of many self-reported measures about what matters. The WMI for adults contains only 5 items that efficiently identify important needs, reliably identify people at risk for future problems, and provide guidance for improving health care and well-being. This report uses data from 10 000 respondents to illustrate the value of a 3-item WMI for adolescents built on the model of the Adult WMI.

A National Pre-Pandemic Survey of Patient-Reported Health Confidence and Implications for Post-Pandemic Practice.

Patient-reported health confidence is a valuable indicator of effective patient-clinician communication, which improves outcomes and reduces costly care use. This national survey examines health confidence attainment in the United States before the COVID pandemic strained health care resources. Health confidence was low for both the percentage of respondents who were financially secure (36%) and financially insecure (18%). Persons enrolled in employer- and union-sponsored plans, who had the highest household income, did not report higher levels of health confidence. Health policy should support the measurement and monitoring of health confidence in clinical practice to improve population health and maximize resource efficiency.

CARE Vital Signs supports patient-centered, collaborative care.

CARE Vital Signs refers to a standard form created by practices to Check what matters to patients, Act on that assessment, Reinforce the actions, and systematically Engineer or incorporate actions into staff roles and clinical processes. On its face, CARE Vital Signs is a deceptively simple tool that, when properly used, can help a practice attain levels of efficiency and quality. This article describes the rationale for CARE Vital Signs and the ways it can be used for the greatest benefit.

Making high-quality, patient-centered care a reality.

The Institute for Healthcare Improvement and others have spent a decade transforming the concept of patient-centered care from the realm of idea to the reality of practice. In this introduction, we provide a summary of this transformation, and the practical steps practices and health systems can take to make their transition to providing more patient-centered care.

Balanced measures for patient-centered care.

The Institute for Healthcare Improvement has long supported the use of balanced measures to assess improvement among patients at both the individual and the population levels. Although biomedical outcomes and process measures have been widely accepted, patient-reported measures are still not in widespread use. The most common use of such measures is at the population level to gauge satisfaction with care long after it has been provided. This article examines barriers and solutions to including patient-reported measures at the point of care.

Insights From Organized Crime for Disorganized Health Care.

During college and medical school, the author's summer employment acquainted him with members of organized crime families. After a full career as a primary care clinician and geriatrician with research on improving health care delivery, the author opines that several insights from organized crime should be of interest to health care professionals: (1) don't damage the host; (2) protect the brand; and (3) lead necessary adaption. From these insights, the author presents symptoms of failure evidenced by the US health care system, followed by several adaptations that would reduce the system's costs, improve its image, and address future challenges.

A Brief Review of Single-Item and Multi-Item Quality-of-Life Measures for Medicare Patients.

Using responses to HowsYourHealth.org from 9068 patients aged 65 years or older, I illustrate measurement compromises for quality-of-life assessment and management.

The impact of primary care patients' pain and emotional problems on their confidence with self-management.

There is a paucity of information about confidence with self-management in primary care practice. This study examines changes over time in patient-reported confidence with self-management on the basis of 1047 patients aged 50-69 who had common chronic diseases, bothersome pain, or emotional problems. We examined the relationship between patients' self-reported confidence, their experiences of medical care, and health outcomes after adjustment for baseline characteristics. We observed that, over a 2-year period, about a third of the patients remained confident and a third remained not confident. Change in pain or emotional problems was strongly associated with whether a patient was confident or not at the end of the follow-up period (P < .001). Persistently good confidence or improved confidence was strongly associated with measures of high-quality medical care. For patients with diabetes, persistent confidence was more often associated with control of blood glucose (P = .004) compared with the control in patients who were not as confident. Confident patients were likely to be fully engaged in everyday work and activities (P < .001). The results suggest that for the majority of patients in primary care practices, the status of their self-reported confidence with self-management persists over time. Their confidence is impacted by their pain or emotional state and strongly associated with their medical care experiences and some outcomes of care.

Reforming the primary care physician payment system: eliminating E & M codes and creating the financial incentives for an "advanced medical home".

The problem faced by primary care physicians is that they can only maintain or increase their (inflation adjusted) incomes by increasing the volume of visits and associated services. The fundamental flaw in a fee-for-service system is that only paying for individual services creates incentives for more services. This article offers a very different approach to paying primary care physicians that will result in both significantly higher incomes for these underpaid professionals together with incentives for creating a medical home.

Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need.

BACKGROUND: Usual medical care in the United States is frequently not a satisfying experience for either patients or primary care physicians. Whether primary care can be saved and its quality improved is a subject of national concern. An increasing number of physicians are using microsystem principles to radically redesign their practices. Small, independent practices-micro practices-are often able to incorporate into a few people the frontline attributes of successful microsystems such as clear leadership, patient focus, process improvement, performance patterns, and information technology. PATIENT FOCUS, PROCESS IMPROVEMENT, AND PERFORMANCE PATTERNS: An exemplary microsystem will (1) have as its primary purpose a focus on the patient-a commitment to meet all patient needs; (2) make fundamental to its work the study, measurement, and improvement ofcare-a commitment to process improvement; and (3) routinely measure its patterns of performance, "feed back" the data, and make changes based on the data. LESSONS FROM MICRO PRACTICES: The literature and experience with micro practices suggest that they (1) constitute an important group in which to demonstrate the value of microsystem thinking; (2) can become very effective clinical microsystems; (3) can reduce their overhead costs to half that of larger freestanding practices, enabling them to spend more time working with their patients; (4) can develop new tools and approaches without going through layers of clearance; and (5) need not reinvent the wheel. CONCLUSIONS: Patient-reported data demonstrate how micro practices are using patient focus, process improvement, performance patterns, and information technology to improve performance. Pati ents should be able to report that they receive "exactly the care they want and need exactly when and how they want and need it."

Clinical microsystems, part 1. The building blocks of health systems.

BACKGROUND: Wherever, however, and whenever health care is delivered-no matter the setting or population of patients-the body of knowledge on clinical microsystems can guide and support innovation and peak performance. Many health care leaders and staff at all levels of their organizations in many countries have adapted microsystem knowledge to their local settings. CLINICAL MICROSYSTEMS: A PANORAMIC VIEW: HOW DO CLINICAL MICROSYSTEMS FIT TOGETHER? As the patient's journey of care seeking and care delivery takes place over time, he or she will move into and out of an assortment of clinical microsystems, such as a family practitioner's office, an emergency department, and an intensive care unit. This assortment of clinical microsystems-combined with the patient's own actions to improve or maintain health--can be viewed as the patient's unique health system. This patient-centric view of a health system is the foundation of second-generation development for clinical microsystems. LESSONS FROM THE FIELD: These lessons, which are not comprehensive, can be organized under the familiar commands that are used to start a race: On Your Mark, Get Set, Go! ... with a fourth category added-Reflect: Reviewing the Race. These insights are intended as guidance to organizations ready to strategically transform themselves. CONCLUSION: Beginning to master and make use of microsystem principles and methods to attain macrosystem peak performance can help us knit together care in a fragmented health system, eschew archipelago building in favor of nation-building strategies, achieve safe and efficient care with reliable handoffs, and provide the best possible care and attain the best possible health outcomes.

Validation of the What Matters Index: A brief, patient-reported index that guides care for chronic conditions and can substitute for computer-generated risk models.

INTRODUCTION: Current health care delivery relies on complex, computer-generated risk models constructed from insurance claims and medical record data. However, these models produce inaccurate predictions of risk levels for individual patients, do not explicitly guide care, and undermine health management investments in many patients at lesser risk. Therefore, this study prospectively validates a concise patient-reported risk assessment that addresses these inadequacies of computer-generated risk models. METHODS: Five measures with well-documented impacts on the use of health services are summed to create a "What Matters Index." These measures are: 1) insufficient confidence to self-manage health problems, 2) pain, 3) bothersome emotions, 4) polypharmacy, and 5) adverse medication effects. We compare the sensitivity and predictive values of this index with two representative risk models in a population of 8619 Medicaid recipients. RESULTS: The patient-reported "What Matters Index" and the conventional risk models are found to exhibit similar sensitivities and predictive values for subsequent hospital or emergency room use. The "What Matters Index" is also reliable: akin to its performance during development, for patients with index scores of 1, 2, and ≥3, the odds ratios (with 95% confidence intervals) for subsequent hospitalization within 1 year, relative to patients with a score of 0, are 1.3 (1.1-1.6), 2.0 (1.6-2.4), and 3.4 (2.9-4.0), respectively; for emergency room use, the corresponding odds ratios are 1.3 (1.1-1.4), 1.9 (1.6-2.1), and 2.9 (2.6-3.3). Similar findings were replicated among smaller populations of 1061 mostly older patients from nine private practices and 4428 Medicaid patients without chronic conditions. SUMMARY: In contrast to complex computer-generated risk models, the brief patient-reported "What Matters Index" immediately and unambiguously identifies fundamental, remediable needs for each patient and more sensibly directs the delivery of services to patient categories based on their risk for subsequent costly care.

A controlled trial of methods for managing pain in primary care patients with or without co-occurring psychosocial problems.

PURPOSE: Pain, a common reason for visits to primary care physicians, is often not well managed. The objective of this study was to determine the effectiveness of pain management interventions suitable for primary care physicians. METHODS: Patients from 14 rural primary care practices (47 physicians) who reported diverse pain problems with (n = 644) or without (n = 693) psychosocial problems were randomized to usual-care or intervention groups. All patients in the intervention group received information tailored to their problems and concerns (INFO). These patients' physicians received feedback about their patients' problems and concerns (FEED). A nurse-educator (NE) telephoned patients with pain and psychosocial problems to teach problem-solving strategies and basic pain management skills. Outcomes were assessed with the Medical Outcomes Study 36-Item Short-Form and the Functional Interference Estimate at baseline, 6 months, and 12 months. RESULTS: Patients with pain and psychosocial problems randomized to INFOFEED+NE significantly improved on the bodily pain (P = .011), role physical (P = .025), vitality (P <.001), role emotional (P = .048), and the Functional Interference Estimate (P = .027) scales compared with usual-care patients at 6 months. These improvements were maintained at the 12-month assessment even though these patients had received, on average, only 3 telephone calls. Compared with usual-care patients, at 6 months patients who received INFOFEED alone experienced minimal improvements that were not sustained at the 12-month assessment. CONCLUSIONS: For patients with pain and psychosocial problems, telephone-based assistance resulted in significant, sustained benefit in pain and psychosocial problems.

Technical notes: when all things are not equal.

This article addresses 2 questions. First, how useful is adult patients' information about health and healthcare when they use the Internet for a "health checkup"? We find that patietns' reports are very strongly associated with medical record information for blood pressure, cholesterol, and blood glucose. Second, what are the biases in information from Internet respondents? Although we find that "health checkup" Internet users seem to be representative for patients in actual practice, much more research will be needed to fully address this question.

An introduction to technology for patient-centered, collaborative care.

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