Case managers improve physician involvement
Physician socialization’ must be overcome
Case managers must confront the fact that, in general, physicians have an innate cultural conflict with the health care system where it involves nonphysicians, says Lynne Nemeth, RN, MS, director of outcomes management, research, and development at the Medical University of South Carolina in Charleston. To address that problem, she says, case managers must employ an array of tools and tactics to gain the support of physicians.
The conflict is based on physician training and socialization, Nemeth explains. The result is that physicians often are not aligned with case managers and have a different focus on the patient and a different time frame for action as well as a different view of resources. According to Nemeth, there are numerous tools that case managers can use to gain the attention of physicians. For example, she says, physicians rely heavily on their experience from their last patient as well as local guidelines, pathways, and continuing medical education (CME).
Other factors that influence physicians include governmental oversight, accrediting bodies, journals, colleagues, training, informatics, and incentives. "Those are just some of the many ways to grab their attention," she says. Relationships are very important, too, Nemeth says. That can include informal power politics, coalition building, and influence.
Francie Handler, RN, BSN, CMC, team supervisor in case management at St. Vincent’s Hospital in Sante Fe, NM, takes a similar view. "Doctors listen to doctors." In the case of St. Vincent’s, Handler says, they also listen to the chief medical officer, whose role she credits with significant enhancements in case management programs. "If we are unsuccessful in getting the doctor on board from the case management perspective, our medical director is very helpful," she says. When those interventions take place, the chief medical officer uses very specific information and makes sure there is an identifiable problem to be addressed.
Numerous approaches can be used to alter physician behavior, such as physician education, employing opinion leaders, and getting involved with academic detailing, as well as audit and feedback, clinical decision support, and physician incentives, Nemeth says. In addition, case management, critical pathway teams, and any other team-driven approaches to the processes of care in decreasing variation also can play a role.
The increase in direct-to-consumer advertising by the pharmaceutical industry presents another approach that alters physician behavior, she says. There is a growing sentiment that marketing to physicians should be explored. "It is almost like market research to better understand how to motivate physicians," she says.
CME may provide information, but it does not necessarily change a practice, according to Nemeth. On the other hand, there is some evidence from the literature that it is productive to spend time doing academic detailing.
Nemeth notes that providing feedback from different projects, such as benchmarking projects and the Health Plan Employer Data Information Set, also are very important. But the effect of providing statistically significant information often can be small to moderate. "We should not rely solely on that approach," she says. "Even though data may be well-developed, they are not necessarily going to impact [physicians’] behavior."
What really needs to be established is real-time feedback, including reminder systems that are built into physicians’ process of care such as computerized order entry, Nemeth says. "You need to build in ways to get the feedback to them at the point of care rather than after the fact so they have to think about it the next time. Reminders have good potential if they are built in in real time."
Handler takes a similar approach. She and her staff employ simple tactics such as leaving easily identifiable notes on the front of the chart. For example, on the orthopedic floor, prescriptions are left for medical equipment, home care, and pharmaceuticals just to ensure doctors don’t forget anything. Doctors then can complete and sign the items they deem appropriate. That creates more work on the front end but saves a lot of time on the back end, she says.
Engage your physicians with technology
Economic incentives are the most specific motivator, Nemeth says, but financial incentives are not always legal and must be matched with the structure of the support system. For example, if physicians can get the state-of-the-art equipment they require for surgical procedures and similar improvements, that can be a motivating factor. "You have to match the incentive to the resources they are asking for," she says.
Collaborative pathways and other case management systems and interventions that are designed to support the patient are all very important, says Nemeth. But in order to get physicians on board to collaborate, doctors must have their own self-interest to engage in the activity.
The hospital’s imperative is to identify how physicians can benefit, and that often involves technology. That might take the form of a new MRI or a microscope in the operating room that allows a surgeon to act with more precision. Such equipment ultimately will reward physicians financially because they have a higher caseload and more patients, she explains.
In short, when a hospital provides physicians with the tools, equipment, and resources they require, whether in material resources or human resources, Nemeth says, "The system recognizes the value physicians bring to playing the game of health care improvement."
Finally, in order to improve patient outcomes, case managers must provide performance data in an informative manner rather than a punitive manner, she says. That means looking at the full range of outcomes, patient and provider satisfaction indicators, clinical outcomes of strategic importance, and cost and resource utilization. This range of tools gives a good sense of balanced indicators that do not approach it solely from the financial point of view.
"The financial point of view alone is not going to motivate physicians," Nemeth says. "They want to provide the highest quality care."
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