As a primary care physician who cared for numerous patients at risk for chronic diseases, I often dreaded that look in their eyes when I explained that they needed to change their lifestyle. It was a look that told me they were thinking this: “That’s interesting information, but what do I do with it? If I knew how to do that, do you think I’d be sitting here in this condition?” This look usually appeared at the moment they realized they were expected to do this pretty much on their own.

It’s the same look I see in many physicians’ eyes when we talk about population health analytics though they feel freer to voice their skepticism: “Great data. Now what?”  The unspoken but implied message is identical to the patients’ thoughts. “If I knew how to prevent chronic conditions, do you think we’d need to have this conversation?” They know they don’t have the resources or knowledge to go it alone, but they don’t see much help on the horizon. And they don’t have much bandwidth for new projects. They barely have time to see all the patients each day who need their help.

Coaching can help both patients and physicians

The remedy for both patients and physicians is coaching. Both live in a society where success with preventing and managing chronic diseases is made more difficult than it needs to be. To fundamentally change habits (in lifestyle or in practice routines) takes committed effort and really good guidance. Patients need health coaching and physicians need coaching to help them adopt best practices in chronic disease prevention and management. Those of us who work in the IT services industry have an opportunity – and an obligation – to help physicians effectively use the technology and resources that are increasingly available to help in this effort. We need to offer coaching services, using a well thought-out framework that can be adapted to fit the needs of individual practices.

Physicians have made good progress in better managing chronic disease, though there is still work to be done in this area. But few have had the time and resources to focus on chronic disease prevention. Though prevention is an extension of the work they are doing to manage chronic conditions, it’s a tougher nut to crack. Patients who are at risk, but not yet experiencing symptoms, don’t feel much urgency to take action, so when a physician sees data about patients at risk, they need a different strategy to address the problem.  

We do have some exemplars of the specific infrastructure, systems and workflows needed to address prevention, but we need to spread this knowledge to all primary care physicians. If you want high-value care, with the best outcomes at the lowest cost, the way to get that care is to help primary physicians become high-value providers, especially in the realm of chronic disease prevention and management.

Of course, knowledge alone isn’t enough. Physicians need the front-end resources to get the job done. The good news here is that Medicare and commercial health plans are moving in that direction, responding to the mounting evidence that new care delivery models help prevent chronic disease, or for those whose disease is already established, prevent complications and hospitalizations. Part of the coaching that needs to happen is to teach physicians how to access these resources and how to integrate new practice patterns into their daily work. For some, that will mean an extension of what they already do. For others, it will mean a complete change in their approach to care. They will need customized coaching and IT expertise to set up the infrastructure to make high-value care a reality.

Big payoff for physicians as well as patients and payers

It’s no secret that most primary care physicians are frustrated by the current health system. They are forced to rush through their days, seeing too many patients and spending too much time on documentation and digital paperwork. That’s not why they went to medical school. They became primary care physicians to make a meaningful difference, to help patients optimize their health and wellbeing. And while making a high income isn’t a priority for most primary care physicians (if it was, they’d be doing something else) they do want to be paid fairly. Despite a modest trend upward the past few years, primary care physicians generally earn a third less than specialists.

Fortunately, there is another model of practice that is far more rewarding for primary care physicians, both personally and financially. This model is demonstrated by a handful of practices across the country that have figured out how to provide the individualized level of care needed for chronic disease prevention and management  while reducing the hassle factor for physicians. These practices are highlighted in a report from the Peterson Institute and Stanford University called “America’s Most Valuable Care.” No matter what the current physician compensation plan, these practices are moving in the right direction to implement the mandatory provisions of the Medicare Access and CHIP Reauthorization Act (MACRA) which aims to pay physicians for value rather than volume.

What struck me about these practices is that the patient-centered, team-based care approach produces not only better outcomes at lower cost, it produces a far more satisfying professional environment for the physicians. They are intimately involved in diagnosis and treatment decisions, but they aren’t deeply involved in all the other details of care and the business of the practice. They have staff who focus on those tasks, and they have advanced practice nurses and physician assistants who take care of patient needs that don’t require their level of expertise.  This intelligent use of a healthcare team also means the physicians are better able to balance their professional and personal lives. Most primary care physicians I know would love to work in a more satisfying professional environment and also have more time for themselves and their families.

Transforming healthcare into a high-performing system that prevents and manages chronic disease requires high-value primary care. But building a team-based, information-driven care model is not an easy task. It takes considerable thought and planning and careful use of technology and infrastructure. Putting all these pieces together is tough for one practice to do. But a skilled IT services team, with a reproducible coaching plan based on best practices and the experience of high-value care providers, can help primary care physicians make the transition to a more satisfying and more effective style of practice. If the health IT services industry can take this opportunity and meet our obligations to help, we can transform the U.S. health system in ways that will be truly world changing.