Meta-Doctor: The New M.D.

Health care has changed significantly over time, yet physician leaders continue to be measured by their clinical expertise1. While these “accidental administrators” have provided important physician leadership in the past, 21st century challenges call for a new generation of leadership. Emerging leaders will not only need well-developed clinical skills, but mastery in four important areas to realize the Triple Aim2 of improving patient care, improving population health, and reducing costs. The four knowledge pillars supporting future leadership include health information technology (HIT), team-based care, quality improvement (QI), and value.

The new generation of physician-leaders are introduced here as meta-doctors, suggesting that medical training should provide them with “insider” clinical knowledge as well as a broad, “meta” perspective. This article is designed to help young leaders develop a vision for their education, linking resources to ideas while tying together the important, yet divergent drivers of contemporary healthcare.

P1: Health Information Technology The age of the paper chart is quickly coming to an end. With the passage of the HITECH Act in 2009, clinical practices without electronic medical records (EMR) will be penalized beginning 20153. Even without this type of legislation, the value of EMRs has grown increasingly indisputable. They help clinicians monitor quality indicators and achieve important practice measures to improve patient care. They also facilitate unprecedented communication between PCPs, specialists, and hospitals – connecting the 2 PCPs and 3 specialists seen by the average patient4. Patient portals are able to extend that communication to patients, allowing them to view their record and communicate with their doctor electronically. EMRs do this while reducing cost and improving patient safety5.

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CITE Training the next generation of physician executives. http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx http://www.kaiseredu.org/Issue-Modules/Health-Information-Technology/Background-Brief.aspx 4 CITE 5 CITE Michigan

nutritionists who 6 7 Best Practices in EMR Implementation: A Systematic Review. while also taking full advantage of EMRs to organize telemedicine consults and external radiology reads. This is not surprising.com/ 8 http://skynet.org/education/10x10-courses 11 http://www.org/news-and-publications/amia-news/clinical-informatics-becomes-board-certified-medical-specialty 10 http://www. and meta-doctors are well positioned to design and lead them. and bolstered by the recent specialization of clinical informatics9.ohsu. quality.blogspot. P2: Team-based Care Team-based care is becoming the norm throughout medicine.org/ 12 http://www. directing their team.edu/~hersh/ 9 http://www. Urban NPCs triage patients. implement health maintenance guidelines. collect data on chronic disease.org/ 13 CMS Innovation Center Keynote Address 14 Reference . http://geekdoctor. and order routine labs and studies before the patient sees their doctor. EMRs for improving quality of care: promise and pitfalls. creating what Atul Gawande has call “pit-teams” of care13. Urban-based meta-doctors spend less time collecting routine data on their patients and practice.mhealthsummit. which are organized around the patient-centered medical home (PCMH)14. albeit more specialized opportunities to lead teams. These pit-teams will grow increasingly complex and interdependent. instead focusing on assessing/planning patient care. future leaders will have much more familiarity with HIT. and value. enroll in programs such as 10x1010. Building on the ideas of pioneers like John Halamka7 and Bill Hersh8. and analyzing data. Meta-doctors are different. as traditional physicians have been resistant to the potential of HIT. and some actually allow it to harm their practice6. Physician-led teams include pharmacists managing Coumadin and diabetes. These physicians find it difficult to bridge the biological-technological divide that is quickly narrowing in health care. or attend conferences through the AMIA11 or mHealth12. Urban-based meta-doctors employ multiple NPCs to create their “pitteams”. In the rural setting. Meta-doctors will propogate the recent explosion in HIT while honing its use to improve patient care while supporting teamwork. meta-doctors are already employing non-physician clinicians (NPC) to care of uncomplicated patient.amia. Hospitals offer the meta-physician similar. Meta-doctors will complete clinical informatics classes at their university.amia.Unfortunately many physician practices fail to realize meaningful use of EMRs.amia. freeing the doctor to maximize his/her value-added time.

P4: Value 15 16 CITE The effect of a rapid response team on major clinical outcome measures in a community hospital 17 The Best Practice. Gawande) – how do we get better24. They have attended conferences through the IHI21 or the CMS Innovation Center22. metadoctors have a unique perspective that is able to approach and solve contemporary problems in health care.gov/ 23 http://www. and integrate these projects into practice. and podcasts23 about QI in health care and business. than physicians16. Although more recently known as the director of the Centers for Medicare and Medicaid (CMS). Aneesh Suneja 21 http://www. and sometimes better. P3: Quality Improvement Quality improvement has quickly become a driving force in medicine and Dr.manage complex diets. They are familiar with Value-stream management19. Don Berwick is often credited with its success17. these new leaders ask themselves a question that has long vexed clinicians (including Dr. He has been a champion of patient safety and quality improvement. Don Tapping 20 Lean Doctors.php. these NPCs provide care that is as good as. Lean principles20. Throughout their development.org/offerings/VirtualPrograms/WIHI/Pages/WIHIArchive. Atul Gawande 25 The Power of Positive Deviance. Their answer is three-fold: use HIT to evaluate the performance of health care professionals and institutions. and NPCs who can perform a range of functions from responding to codes15. With non-physician providers collecting data and managing multiple elements of care. Charles Kenney 18 CITE article 19 Value Stream Management for Lean Helathcare. By integrating this broad knowledge with their clinical training. while consuming books.aspx 24 Better. Dr.org 22 http://innovations. http://www. Berwick’s early achievements included co-authoring To Err is Human18 and founding the Institute for Healthcare Improvement (IHI). Pascale . to managing uncomplicated hospital patients. find positive deviants25 who have mapped out change and improved their performance.org/listen. Through specialization.cms.healthaffairs. articles.ihi. Some choose to dedicate this time to quality improvement. Meta-doctors are uniquely positioned to further this important mission. and other topics mentioned in this article. Six Sigma (CITE).ihi. meta-doctors can focus on their patients and their practice.

As was illustrated by the HITECH and the Affordable Care Act. the drive to innovate extends all the way to national policy. or attend the conferences mentioned in this article. or pursue a fellowship at the IHI or in health informatics. meta-doctors will be able to develop their own ideas about the pillars that support them and their confidence will grow.). meta-doctors are confronted by unprecedented opportunity for innovation on multiple levels of the health care system.aafp.onemedical.gov/baldrige/ .com/ http://www. The opportunities for producing value are immense. the PCMH28. Within these microcosms of leadership. etc. In short. with the aim of increasing value by eliminating waste. Intermountain Health. MBA. Medical-students may choose to pursue dual degree programs (MPH. Clinics like One Medical Group26 or Chen Med27 were developed by meta-doctors who implemented many of the ideas discussed in this article to achieve significant reductions in cost. This clinic model is designed to lower costs and improve care. while focusing on the patient and teamwork. read extensively outside of their classes. While meta-doctors skill would be welcomed at the policy level. The first steps will not be easy to discern. When these “future” leaders least expect it.com/ http://www. they will find that the future has caught up with them. while applying 21st century tools to solve 21st century problems.Alongside quality. and recently achieved wide recognition of. but commitment over time will bring communities of leaders together.org/online/en/home/membership/initiatives/pcmh. Residents may choose to get involved with the QI process in their hospital. The American Academy of Family Physicians has long pushed for.html 30 http://www.nist. “How Do I Get There” The steps needed to get “there” from “here” are not easily identifiable and role-models are hard to find.chenmed.org/index. Larger medical systems like Kaiser Permanente. 26 27 28 http://www. Meta-doctors are found at the helm. while improving patient care. attend conferences. With health care spending slated to approach 50% of the United States GDP by 2050. cost reduction has become a central pillar of modern health care. these leaders are retooling the relationship between doctor and patient. Denver Health (a recent Shingo Prize29 Winner). and Henry Ford (a recent Baldrige Award30 winner) are tirelessly pursuing an agenda of continuous quality improvement.html 29 http://www.shingoprize. changes are needed on the ground.

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