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A Health System That Works

Oliver Fein: What is it that allows an individual to express their humanity, to essentially be able to fulfill their human promise? Well, there are certain things, like education, that we think allow for that, like political expression, freedom of expression; but, if you don’t have health, all the education will mean nothing.


My name is Oliver Fein and I am a physician working at the Weill Cornell Medical College where I am the Associate Dean and also Professor of Clinical Medicine and Clinical Public Health.


Question: What obstacles limit access to quality healthcare?


Oliver Fein: The financial access is extremely important as a primary baseline. That’s why I’m interested in the issue of national health insurance. But, once you get over that barrier, there are going to be other barriers that have to be transcended. Among those, it seems to me, are things like health literacy, the degree to which things are interpreted for people so they really understand the decisions that they’re making when they access healthcare. In terms of the rural side of the United States, there is a whole issue of geographic accessibility, the ability to get to healthcare and frankly we’re going to be able to do some great things in that territory, given the whole internet and ways in which consultations should be possible for physicians and nurse practitioners that are in remote areas. They’ll be able to use technology to get to consultations with specialists, that kind of thing.

And then thirdly, there’s the whole issue of the doctor-patient relationship and communication within it. There I think what we should be moving towards is what increasingly is being called the “patient-centered medical home.” Everybody should feel that they have a medical home in this country. What does that home consist of? Not just a doctor, not just a nurse practitioner, but a whole team of people who are there to provide care to people.


Question: How would you design a medical home?


Oliver Fein: The way it works, in my mind, is that there would be a group of providers, so to speak, in an office. If I am dealing with patients who have diabetes and hypertension, a number of chronic illnesses, I will have access, right in that office, to a nutritionist who could advise patients how to alter their diets, to deal with their problems with diabetes, with obesity, with hypertension, those kinds of things.

That in addition, there might be an outreach worker in the office. Someone misses an appointment, they’re called up, and we ascertain why they missed the appointment. We might even arrange for some kind of a home visit to that patient as a way of really having the office extend beyond just the office.

And then thirdly, and very importantly, is that a lot of what we would do is coordinate a person’s care, be able to link them to the appropriate specialist when that was needed, to become a real gateway to care. I’m no talking about this whole idea of a gate keeper that kind of keeps people away from care, but rather facilitates and coordinates the care that people get from specialists.


Question: How can we improve healthcare outcomes?


Oliver Fein: When we measure quality in healthcare, there are kind of three different types of metrics.

One of them is what we call a structural method. Do you have a license? That means have you passed an exam of some kind. Not a very really good measure of quality, to be honest, because it’s not continuing and so forth.

Secondly, are process measures like, did the doctor actually get a mammogram on a woman to rule out breast cancer? Did the doctor do a test for diabetes? Those kinds of measures, and they’re good, but they’re important but the goal standard usually is outcome.

Has there been a difference made in terms of the control of the diabetes, the control of the blood pressure and so on? So increasingly there is discussion about, do we reimburse doctors? Do we pay them in any way relative to quality? And do we pay them to perform well? I think that’s a good idea provided that one is aware of some of the pitfalls, and the vulnerable populations are the pitfalls, frankly. Let’s say we’re going to pay people more if, in fact, they did preventive interventions, had good outcomes, and what happened was that we would pay people less who didn’t have that, doctors who didn’t have that, and those doctors frequently might be serving poor communities where people didn’t always take their medications because they couldn’t afford them. Where there might have been problems with the job they got lost, and they got unemployed and really their health was the second priority, getting the job was the first.

We would have to think of ways to deal with those kinds of circumstances in a, what we will call pay for performance system, so that the doctors serving the vulnerable populations didn’t get paid less and less because they weren’t able to provide the outcomes that somebody who was dealing with an Upper East Side population was dealing with.


Question: Is there hope for a fully integrative medicine?


Oliver Fein: Actually, integrative medicine is an important component of what medicine should be delivering today. By that I mean, let’s think in terms of, again, diabetes, hypertension, obesity, those chronic illnesses that are very prevalent in our society. The physician intervention is frequently, take this pill, or take insulin for the diabetes, and the pill for the hypertension. But we we need to pair that with nutritionists who are helping people deal with their diet, weight loss and things of that sort. We need to pair that, frankly, in high blood pressure, with stress reducers. We should be, in fact, incorporating in our practices referrals for exercise training, maybe even yoga training to deal with stress. That’s why this team-based care that I was describing earlier, the patient-centered medical home, which had really a whole variety of providers in it, not just doctors, seems to me be the way to move. So, integrative medicine should be very much a part of what doctors are involved with.


Question: How important are electronic medical records to your practice?


Oliver Fein: I can say, from my own practice, that we are completely paperless now. The hospital is just about completely paperless.

What it means for patients is that when I’m not able to be on call, let’s say over a weekend, but my partner is, my partner can go directly to my medical record, and see what the patient’s medication are, can see what’s happened recently, what the latest laboratory studies were, and so on. It really provides a way of improving the quality of the relationship between doctor and patient.

Then the other thing is, that it does lead to things that I would call better patient safety. That is to say that, prescriptions that used to be handwritten could be misinterpreted, particularly with my handwriting, by the pharmacist. Now, all of my prescriptions are printed out. There is no chance for this kind of misinterpretation.

What we’re not doing, now, in medical records is that my medical records aren’t accessible if my patient is in Florida, or on the West Coast, or for that matter, frankly, going to another hospital here in New York City.

Somebody is brought by an ambulance to St. Luke’s Roosevelt, rather than to New York Presbyterian, they don’t know what I’ve done. And that interconnectivity of medical records is really the promise of a good computerized medical records system.


Question: What is the next big medical breakthrough?


Oliver Fein: The real thing that I think isn’t talked about a lot is the phenomenon of what is now being called epigenetics. What that means is that the gene may not be as important as the environment in which it develops. That gets back to the medical home, that gets back to trying to truly alter essentially the problem of obesity, which is rampant now in the country. If we can deal with those epigenetic phenomenon, if we can create practices that are really able to embrace dealing with those problems, then in fact, the true benefit of genetic technology will be able to be realized. But up until that time, the epigenetics are going to shape a lot of what’s possible in the genetic revolution.


Recorded on: May 22, 2009.

Watch Dr. Oliver Fein, one of the leading advocates for a single-payer national health plan, explore innovative new ideas for improving access and saving lives.

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