Time for change in education

I spend most of my time thinking about how to improve a broken health care system, and how to leverage information technology to enable improved health care processes.  But, our educational system is also broken.  And, information technology can also enable improvements in education processes.

In a New York Times op-ed this week, David Brooks describes the “tsumani” of change coming to the field of higher education, as web-based distance-learning approaches are embraced by top tier universities and threaten to disrupt the traditional campus-centric approach. Although some of the respondents defended the humanism of face-to-face education, most acknowledged the need for change, and embraced the concept of leveraging the internet to enable a more effective system. I think this trend is long overdue.

I am grateful for the education that I received from the University of Notre Dame and the University of Chicago.  As years have passed, I have come to appreciate the value of that education more, not less.  But, to be honest, there is a lot of room for improvement.  Far too much of the traditional college education process takes place in large lecture halls in which a fraction of the enrolled students attend lectures and take notes for many others who don’t find it sufficiently valuable to show up.  At the front of the lecture hall is a person who was selected and promoted for his or her ability to pump out research papers to be published in journals that often have little editorial rigor, a small actual readership and questionable impact.   Too often, the lecturer was not selected or promoted for being a talented lecturer.  And, since true talent at lecturing is rare, even good local lecturers are unlikely to be as good as the top lecturers around the world.  Because many classes are large, the tests often are quite mechanical, thereby creating a system of incentives in which the students focus on mechanical learning — regurgitating a fact base, rather than developing latent talents, honing skills and acquiring insights.  Then, students participate in labs or discussion seminars led by graduate students that were not selected for their ability to lead discussions.  Furthermore, as shown in the graph below prepared by Mark Perry,  our system of higher education has been growing more and more expensive, putting it out of reach for more people.

I don’t think the problem is with the educators.  As with doctors, educators do heroic, creative things to achieve the best outcomes they can. Rather, the problem is with the system.  As taught by one of my health care heroes, Don Berwick, “every system is designed perfectly to achieve exactly the results it gets.”

I am hopeful that web-based education will disrupt this old system, driving up effectiveness and driving cost way down, thereby increasing access.   I am encouraged by the high quality level of such resources as Khan Academy, an absolutely fantastic collection of interesting free lectures taught by amazingly talented lecturers.  Schools use these lectures to turn the classroom “upside down,” pushing the lecture portion of their teaching to homework hours, leaving the in-school time for students to work together and receive individual and small group coaching from the teachers to address any remaining confusion about the subject material and provide experiences that deepen learning.

But, I think the transformation will go beyond just shifting classes from physical to virtual classrooms.  I think it might lead to a system in which many more people get involved in teaching, mentoring, and coaching, and in which people can continue their education and development throughout their lives.  Our traditional process for higher education ends quite abruptly at graduation, with ongoing contact between educational institutions and their alumni focused more on fund-raising than continuing education.  And, our approach to human resource development in the workplace tends to go through periods of fad and famine.  The fads sometimes seem to be initiated by new leaders who want to demonstrate something about their leadership style, rather than a sincere and persistent effort to develop people over time.

But, when I was  in medical school going through a general surgery rotation, the department chair repeatedly implored his students to subscribe to a few medical journals to begin to build their own libraries and get familiar with the community of people that contribute to those journals.  He wanted us to become engaged in lifelong learning and to become members of those communities.  Of course, we looked at him like he had three heads — as if we could afford to spend hundreds of dollars on journal subscriptions and spend time reading them when we had tests to study for.  But, he was right in ways I did not appreciate for years.  In my professional life, when I have had the opportunity to mentor others, I have always found it rewarding and beneficial to my own learning.  When I have had the opportunity to be mentored and coached by others, I have always valued the experience.  And, when I have taken the time to read and write about advancing the field, I have felt a satisfying sense of belonging and camaraderie within our professional community.

I look forward to an educational system that blurs the boundaries between the campus experience, professional continuing education, human resource development and professional networking.  Imagine a pre-graduation higher education process that places far more emphasis on establishing ingrained habits for lifelong learning and creating durable learning networks that can morph over time as the learner moves through different industries and grows to higher levels of responsibility and leadership. Imagine university faculty continuing to check in on their students over many years.  Imagine social networking tools that go beyond just connecting people with similar interests to creating a vehicle for mentoring and teaching, perhaps with capabilities for testing and assessment, educational and career goal setting, and  financial or non-financial rewards for faculty.

Forward looking health care organizations are already pursuing some of these changes. For example, the Henry Ford Medical Group has established new processes and web-based tools to integrate continuing education, assessment and evaluation, credentialing, and professional networking for residents, fellows and senior staff physicians, facilitating and incentivizing lifelong learning and professional development.  These developments make me hopeful that our educational system is about to dramatically improve, and that the benefits will spill over into our health care system.

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Improving Adult Flu Immunization

Background

The US Preventive Services Task Force established national evidence-based guidelines for adult immunization as part of their 1993 and 1996 review processes. After a review by Henry Ford Health System (HFHS) general internists, family practitioners, and infectious disease specialists, these guidelines were endorsed by the HFHS Prevention Committee. The Prevention Committee’s recommendations were subsequently accepted by the Henry Ford Medical Group Clinical Practice Committee and by the Health Alliance Plan Quality Management Committee to form practice guidelines for the medical group and health plan, respectively.

Methods

A multi-faceted implementation approach was used to improve immunization performance within the Henry Ford Medical Group, one of the provider groups that serve the Health Alliance Plan. Multi-faceted implementation efforts have been found to be most effective for improvement processes that involve behavior change. The implementation effort involved staff training, patient and member education, continual quality improvement, and medical informatics facets.

  • Staff Training.  All senior medical staff within the Henry Ford Medical Group were sent a copy of internal adult immunization guidelines, which were incorporated into a larger preventive health services manual. In addition to this mailing, a number of clinicians had the opportunity to discuss these guidelines in an on-site continuing medical education program on the provision of preventive health services.
  • Patient education was accomplished by publishing an article in the Health Alliance Plan’s member newsletter, which is mailed to all health plan members. A slogan and cartoon character were also developed for a program to promote immunization compliance. This content was incorporated into posters and tent cards, which were placed in clinics lobbies and waiting areas.
  • Local continuous quality-improvement teams were established to develop and implement process changes. These teams launched Saturday morning walk-in flu immunization clinics during flu season. By using this approach to immunization, wait times were reduces and patients were able to avoid setting up an appointment to get the immunization.
  • Medical informatics approaches were pursued, leveraging the capabilities of the clinical information system and data depositories that are available within the insitution. Computer-generated reports were created, listing immunization status for HFHS adult patients. These reports were used by staff of the Saturday morning walk-in flu clinics. In addition, computer-generated reminder postcards and letters to patients at high risk for influenza were printed and mailed.

Evaluation

These mailings were formally evaluated in a randomized trial conducted during the first year of the HFHS flu immunization program. The entire patient population for whom flu immunizations were indicated were randomized into four groups. The control group (usual care) received only the posters and tent cards in the clinic. Patients in each of three treatment groups received this same clinic-based intervention and either (1) a generic postcard, (2) a tailored postcard, or (3) a tailored letter containing an explicit statement of why flu immunization was indicated for them. Indications included age over 65 and the presence of one of a number of disease states, as ascertained from diagnosis coding of ambulatory visits and inpatient admissions. These letters or postcards were addressed from the patients’ primary care clinicians. The results of randomized trial showed a 5 percentage point increase in the rates of immunization in the patient population receiving the tailored letter compared to those receiving usual care.

The cost of the letter, including printing and postage, was 42 cents. The vaccine costs just over $4.00. From the literature, it is known that annual hospital costs are reduced from an average of $355 to $215 as a result of flu immunization. Therefore, during a non-epidemic year, the flu immunization program was calculated to save the HFHS over $180,000, net of the cost of the intervention. During an epidemic year, this savings is increased to almost $400,000. Therefore, the flu immunization project serves as an example of a clinical-practice improvement effort that simultaneously benefits the health status of patients and reduces health care cost.

The National Committee for Quality Assurance (NCQA) adopted in 1996 a new adult immunization performance measure which is included in the Health Plan and Employer Data and Information Set (HEDIS 3.0). These quality indicators have been reported by hundreds of health plans across the country, and are compiled in the NCQA Quality Compass, a national health plan quality database.

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The Managed Care College and Pediatric Asthma Management

The Managed Care College

The Managed Care College is a comprehensive professional development program that is intended to go beyond the transfer of information. It attempts to persuade clinicians that change is necessary and desirable, to provide leadership and guidance in seeking change, to create opportunities to collaborate with colleagues in planning and implementing change, and to provide ongoing provider performance feedback to monitor change. The College is an on-site, continuous program. The notion behind the College was that continuing medical education should not be removed from everyday clinical practice, but instead should be a part of it. The College offers a variety of courses, ranging from clinical epidemiology to customer oriented service provision. There is also a series of courses directed at specific conditions.

Pediatric Asthma Management Course

One of the courses within the Managed Care College focused on the ambulatory management of pediatric patients with bronchial asthma.  Within the context of this asthma course, and with guidance from course faculty, the participants did the following:

  • Completed directed reading and received a lecture to review the epidemiology and pathophysiology of asthma,
  • Agreed on a definition of pediatric asthma, based on billing codes.  To inform this process, participants conducted a chart review from an initial computer-generated list of their own asthma patients to identify coding issues.  Based on agreed-upon definitions, a registry of asthma patients was established for each participant.
  • Studied and discussed the implications of a computer-generated list of their own patients in the asthma registry, flagging patients with a recent emergency room visits and admissions and those who had submitted no claims for inhaled steroids, a preventive treatment for asthma. The list also identified the 20% of patients who had been seen by an allergy specialist, or who had poor continuity of care by primary care clinicians.
  • Reviewed externally developed guidelines for patients with bronchial asthma. These guidelines were then discussed within the context of specific patient scenarios to evaluate the appropriateness and feasibility of adapting them within the HFHS.
  • Developed a clinical-process flowchart to identify barriers to implementation of asthma guidelines, with special focus on barriers to patient education.

With this as background information about their own clinical practices, and after having reviewed a number of externally developed guidelines, the class adapted the National Heart, Lung, and Blood Institutes guidelines for the diagnosis and management of pediatric asthma. Ultimately, after several reviews and approvals, those guidelines became the guidelines adapted by the entire HFHS. As part of these guidelines, some specific tools were developed. For example, a standardized “zone sheet” was developed, including an action plan for the patient to follow depending upon their self-measurement of peak expiratory flow rate. A peak-flow diary was also created to record results of self-monitoring.

Evaluation

As part of a formal program evaluation of the Managed Care College, pre- and post-surveys were administered to all course enrollees.

  • At the end of the course, enrollees were more likely to agree that they understood the “zone sheets.”
  • Enrollees were also more likely to indicate that home monitoring of peak expiratory flow rates was important, consistent with the practice guideline.
  • Sixty four percent of enrollees indicated that their participation in the course changed their approach to the management and treatment of patients with asthma.
  • Almost three-quarters agreed with the statement that participation in the course increased the percentage of patients for whom they recommend home monitoring of peak flows.
  • About 63% said the course increased the percentage of patients for whom they prescribed preventive or maintenance medications.
  • Just over 50% indicated that participation increased the frequency with which their patients with asthma received education.
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