By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Change was indeed possible, one person at a time.”

–Mark Bello, Author

The topic of Health Equity is now everywhere: special issues of Health Affairs and JAMA^®, legislation, regulatory mandates, etc.

What does it mean for Partnership HealthPlan of California (PHC) and primary care?

The Department of Health Care Services (DHCS) has a nice framework for thinking about Health Equity (from the 2022 Comprehensive Quality Strategy).
It divides Health Equity into three categories of actions:

1. Measurement: Activities related to accurately measuring disparities and inequities. This includes a planned several-year effort to collect Sexual Orientation/Gender Identity information as part of the Medi-Cal eligibility process (in addition to current gathering of race/ethnicity/language data). Overall quality data and outcomes can then be analyzed for each of the demographic groups for which we have data, to look for differences or disparities. These differences may be found at the county, health plan, or provider level, depending on the individual measure characteristics. Example: the rate of BP control is significantly lower for Black men, resulting in increased incidence of stroke and heart attack.
2. Interventions: Once disparities or inequities are documented, they can be analyzed to look for drivers or underlying causes. This analysis can then be prioritized into some potential action plans or interventions to close disparities/reduce inequities. There are two major potential causes of confirmed inequities in vulnerable populations:
   1. Bias/Discrimination. This can occur if a health care professional or support staff make treatment decisions or recommendations based on implicit bias or even explicit assumptions about patients’ values and options, based on their race/ethnicity/language or other trait, and withholds valuable care disproportionately to one group compared to another. Example: Post partum nurses in one PHC contracted hospital don not educate new Latina moms about breastfeeding because they assume that Latina mothers prefer to bottle feed. Provider Intervention: Staff education to understand implicit and explicit bias and learn to counteract it. Societal Intervention: Educate each other and particularly our children at a younger age to understand implicit and learn to compensate for it, so that those who choose to work in health care don’t come with biases to be unlearned.
   2. Systemic or Socio/Cultural/Economic Factors. Different levels of income, family support, educational attainment, quality of housing, neighborhood safety may be associated with different demographic groups and be a major driver for unequal health outcomes. Example: Differential rates of obesity, hypertension and diabetes in different demographic groups, which lead to differential morbidity and mortality rates. Provider Intervention: Extra in-reach and out-reach activities, including addressing key social needs to have the health care team overcome the underlying socio-cultural factors and improve health care quality outcomes despite the underlying systemic factors. Societal Intervention: Support federal, state and local policies and interventions which reduce the underlying social and economic factors driving the difference.
3. Supporting a Culture of Diversity, Equity, and Inclusion (DEI)in the workplace. Strictly speaking, activities to support DEI in the health care workplace are a societal-level intervention to reduce bias and inequities, but the ideals of DEI in a health care organization support that organization’s propensity to the meaningful interventions listed above. Examples: Designating someone in the health care organization’s leadership to spend time and energy focusing on equity; supporting an employee equity committee that reviews HR data, and practices for potential interventions.

PHC will follow DHCS’ lead and direction in using the the National Committee for Quality Assurance (NCQA) Health Equity Framework as a foundation for extending our previous work in population health/health equity to a new national standard. This new standard includes all three activities above: better measurement of disparities, focused and effective interventions to reduce/eliminate disparities, and activities to support DEI among our staff.

We encourage you to work toward improving health equity in these same three realms.

1. Use data you have in your electronic systems to analyze disparities that you may be able to detect better than PHC, which now uses only county-provided demographic data usually self-declared in the Medi-Cal eligibility form.
2. When you identify potential disparities either from the data analysis in step 1 or from direct feedback from patient complaints or feedback, evaluate options for how to reduce this disparity.
3. Discuss any changes your company can make to support staff having a greater understanding of implicit bias, the historic roots of racism and other discrimination, and ways to compensate for this.

Finally, put your organization’s plan in writing and review it periodically at all-staff meetings, to keep the momentum in the right direction.

We all need to do our part to make our health care delivery system more equitable.

For more materials on health and racial equity, see the California Healthcare Foundation, the Center for Health Care Strategies, and Health Begins.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Leadership is the art of getting someone else to do something you want done because he wants to do it.”

– Dwight D. Eisenhower

As we emerge from the constraints of the COVID pandemic, we are spending important and deserved energy on restoring our systems and staffing. At the same time, we are trying our best to respond to a flood of new regulations, programs, and provider types.

Given all these activities and external stresses, we have been less engaged with community partners and advocacy efforts. This impacts our effectiveness in addressing challenges in our communities. Lack of engagement also leads to less robust feedback in the policy development process, which impacts the effectiveness of these policies as they roll out.

There are many levels of collaboration in which clinical leaders can and should participate. October’s newsletter focused on county medical societies, and November’s newsletter focused on community collaboratives. This newsletter focuses on state-wide trade organizations.

State-wide Trade Organizations: These may include specialty organizations like the California Academy of Family Physicians or the California Chapter of the American Academy of Pediatrics.

They may also represent your practice setting like the California Primary Care Association; the California Rural Indian Health Board; the California Rural Health Association; the California Association of Rural Health Clinics; the California Association of Public Hospitals; and the California Hospital Association. Most of these organizations have committees for clinicians and opportunities for clinical leaders to give input. They make better policy recommendations and formulate better strategies when practicing clinicians are involved.

Trade organizations allow clinician leaders to develop a support network of peers, share best practices with each other informally, and give input on current policy issues that are complex or controversial.

Summary: In addition to leading within your organization, clinician leaders need to engage with outside organizations. It is hard to find time to participate optimally in all these areas. One option is to divide up the workload with other budding clinician leaders in your organization. They often enjoy this break from their clinical work, and it makes them feel like they are a part of something larger than their own clinical practice.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Out of clutter, find simplicity. From discord, find harmony.
In the middle of difficulty lies opportunity.”

– Albert Einstein

As we emerge from the constraints of the COVID pandemic, we are spending important and deserved energy on restoring our systems and staffing. At the same time, we are trying our best to respond to a flood of new regulations, programs, and provider types.

Given all these activities and external stresses, we have been less engaged with community partners and advocacy efforts. This impacts our effectiveness in addressing challenges in our communities. Lack of engagement also leads to less robust feedback in the policy development process, which impacts the effectiveness of these policies as they roll out.

There are many levels of collaboration in which clinical leaders can and should participate. Last month’s newsletter focused on county medical societies. Next month will cover statewide trade organizations.

This newsletter focuses on local community collaboratives.

Local Community Collaboratives:
In one form or another, each of our counties has one or more health collaborative stakeholder groups. Examples include:
•    Hope Rising, Lake County
•    Health Action 2.0, Sonoma County
•    Shasta Health Assessment and Redesign Collaborative (SHARC)
•    Live Healthy Napa County
•    Vida Del Norte

Health care provider stakeholders meet together to either keep each other up to date on their major initiatives (helpful for preventing surprises and to look for opportunities to work together) or to actively work across organizations on a common problem (like prescription opioid overuse or adverse childhood events). Major stakeholders may include hospitals, larger medical groups, FQHCs, the county medical society, and the county health department. Sometimes additional community-based providers or even consumers are also included. As a community-based health plan, Partnership HealthPlan of California (PHC) tries to participate in all coalitions of which we are aware.

In many collaboratives, all or most of the stakeholders are non-clinicians. These can achieve the first goal above of giving updates and preventing surprises. In a few communities, clinician leaders representing the different health care providers meet monthly or quarterly. This would typically include the CMO of health centers, the county health officer, an officer of the county medical society, and clinical executive leaders for local hospitals. These can be in parallel to the non-clinician collaboratives. Clinician-level sharing is at a different level than non-clinicians, so having these separate cross-provider meetings can bring additional ideas and group interventions on community health problems.

Many county health departments have a requirement for a community stakeholder process to contribute to their county public health priorities. Often these stakeholder meetings are run by consultants, include some sort of survey (which clinical leaders should try to contribute to), and a series of community meetings. While this process is very time consuming, participating in community prioritization exercises can have some impact on county funding priorities, so it is important to hear the voice of community clinician leaders in that process.

What local community collaboratives exist in your county? Is there someone on that collaborative that represents the primary care providers like yours?

If you are unsure what groups are active in your county or want to strategize on boosting effectiveness of current groups, reach out to your regional PHC staff: your Regional Medical Director, Regional Manager, county Provider Relations Representative, or regional QI staff. None of our work is really siloed; we all need to build relationships to tackle the most challenging issues in our communities.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I think the reason I’ve been so committed to advocacy is because I see so many people in pain.”

– Olly Alexander, British Actor

As we emerge from the constraints of the COVID pandemic, we are spending important and deserved energy on restoring our systems and staffing. At the same time, we are trying our best to respond to a flood of new regulations, programs, and provider types.

Given all these activities and external stresses, we have been less engaged with community partners and advocacy efforts. This impacts our effectiveness in addressing challenges in our communities. Lack of engagement also leads to less robust feedback in the policy development process, which impacts the effectiveness of these policies as they roll out.

There are many levels of collaboration in which clinical leaders can and should participate in. I want to highlight three that are particularly worthwhile: County medical societies (more detail below), local community collaboratives, and statewide trade organizations. The latter two will be the subject of future newsletters.

Organized Medicine/County Medical Societies 
County medical societies can serve several important functions:

1. Promote the value of professionalism in the field of medicine
2. Provide a social support network for individual clinicians
3. Promote policies and programs that support and advocate for public health
4. Promote policies aimed at improving the health status of the entire population

The California Medical Association (CMA) has a respected and powerful political voice in Sacramento. There are times organized medicine may vote to promote a policy we individually disagree with; however, the process of directing the policy priorities is remarkably democratic. That process depends on participation by local county delegates and regional trustees that take the time to learn about health policy and participating in the process.

Some medical groups in more populous areas have more influence in the CMA because they have all their physicians join their local medical societies. Conversely, medical society membership and delegate representation is low in rural areas often leading to unaccounted physician views on policy issues.

At a minimum, the clinical leaders of a Primary Care Provider (PCP) organization should be active medical society members. If your organization’s budget can accommodate it, covering the cost for any interested physician to join the medical society is a best practice. Having the organization or medical group pay for all physicians to be members will give your organization a bigger voice and is certainly worth considering.

Next month: Engaging in Community Collaboratives.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The search for a scapegoat is the easiest of all hunting expeditions.”

-Dwight D. Eisenhower

Case Example: A 45 year old woman sends a secure electronic message to her primary care clinician, asking what she should do for her “heartburn.” Her PCP works a 3 day per week schedule at a chronically understaffed rural health center, and finally gets to the patient’s message at the end of a long day. The PCP does not ask any additional questions, but suggest the patient try OTC famotidine for a few days and call back if the “heartburn” is no better. Two days later, the PCP receives an electronically communicated consultation note from the local hospital, that the patient was admitted to the ICU in cardiogenic shock from a massive myocarial infarction. Glancing through the electronic health record, the clinician notes that the patient’s mother and father both died in their 40s of heart attacks.

This case of diagnostic error is certainly partly due to the PCP not performing an adequate assessment of the patient: not reviewing the electronic health record for background information, not asking additional questions to find out what the patient meant by “heartburn” or asking about red flag symptoms.

However, several system issues also contributed to the diagnostic errors: the overworked clinician, more prone to shortcuts to get through their day; the PCP’s reduced in-office schedule; the promotion of electronic communication to increase access to clinician; the lack of the PCP’s experience with rarer but more serious causes of “heartburn” because an emergency room/hospitalists sees all patients in the hospital.

The Institute of Medicine’s 2015 book “Improving Diagnosis in Health Care,” categorizes such system issues that contribute to diagnostic inaccuracy into five groups:

1. Organizational factors, such as schedules, staffing models, payer mix, and leadership.
2. Physical environment, including clinical ambiance, proximity to co-workers.
3. Tasks, which may compete for the attention of the clinician, like electronic medication refills, or which may not occur when they need to, like following up abnormal lab results.
4. Technologies and tools, such as the configuration of the electronic health record, and the use of electronic modalities for virtual care.
5. Diagnostic team members, including who is included on the team (adding a triage nurse for example), how communication occurs with the team, and the sense of responsibility team members feel to collaborate (in the case above, none of the physicians caring for the patient in the hospital called the PCP about the admission).

These same five factors contribute to clinician burnout and to health care inequities, so we as clinician leaders have a triple responsibility to spend our discretionary time working to steadily optimize this work system, the external environment that our clinicians work within. This is true for all clinician leaders, whether we work in primary care, specialty care, institutional settings like hospitals or skilled nursing facilities, at a health plan, or a government regulator.

At the same time, individual clinicians must continually strive to improve their own diagnostic processes, being aware of their own cognitive biases and short cuts, and reinforcing a sense of professional responsibility to achieve diagnostic excellence even with the shortcomings of the system we work in.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Those who do not remember the past are condemned to repeat it.”

-George Santayana, Philosopher

One casualty of the Covid pandemic is institutional memory. There has been a big turnover in staff, management, and leadership positions in many health centers, offices and hospitals in the Partnership HealthPlan of California (PHC) service area.

Example A: A new clinic manager tries to increase provider access by making provider appointments shorter. This results in more patients being seen per day. However, over time the provider feels burnt out and quits to join another clinic, resulting in even longer waits for patients.

While new staff can bring new ideas, they often don’t have the benefit of knowing what has been tried before, and how well it worked. Often problems are approached as if no one has ever tried to fix them before. As a result, they repeat previous ideas and the lessons learned are no different from the first try.
The concept of Knowledge Management includes three components:

1. Using existing knowledge to inform pilots and interventions, instead of starting from scratch.
2. Generating new knowledge by processing and analyzing information and existing knowledge in new ways.
3. Capturing new knowledge in a way that can be searched and accessed easily in the future.

The first component can be summarized succinctly: “Don’t reinvent the wheel.”

When mentoring new staff with shiny new ideas, show them how to find out what is known about that idea. This includes internet searches, talking to staff and outside experts with more institutional wisdom, and looking though company files about past projects.

Background research also includes subjecting articles and papers to scrutiny, to identify bias and statistical fallacies that could reinterpret their findings.

Example B: A new physician decides to implement a scribe system to improve provider efficiency. They consult articles and talks to a colleague at a neighboring health center to look for additional information. This results in phone conversations with clinical leaders at several other health centers, where they learn that clinic productivity does not tend to improve with the use of scribes, but that chart accuracy, clinician happiness, and quality scores improve when a scribe program is implemented well.

Sir Isaac Newton (a co-discoverer of calculus and father of the field of physics) understood this principle of building on prior knowledge. “If I have seen further, it is by standing on the shoulders of giants.”

As leaders we must model this framework, setting an expectation for the new staff that join our organizations, that they will search out existing knowledge and apply it to the problems they confront.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Constantly talking isn’t necessarily communicating.”

-Charlie Kaufman, playwright/screenwriter

A Spanish-speaking patient calls her primary care health center, and talks with a triage nurse who speaks Spanish. She says her 5 year old son was seen in an emergency room in Southern California and told that her son has Monkeypox. She was given an appointment, the patient was roomed and the medical assistant recorded the chief complaint of Monkeypox.

It turns out, that the patient had infectious mononucleosis (this was what was diagnosed at the emergency room). How did this get misinterpreted?

The answer: Medical Spanglish!

The medical translation of Monkeypox is viruela del simio, but a more colloquial translation is viruela del mono. Viruela is the Spanish translation for Smallpox, so viruela del simio means Smallpox of the simians, and viruela del mono means “Smallpox of the monkeys.”

In contrast, the medical translation of infectious mononucleosis (or acute Epstein-Barr virus infection) is mononucleosis infecciosa or infeccion por el virus de Epstein-Barr. If the emergency physician had used one of these terms, there would not have been the confusion that ensued.

However, the emergency room physician spoke a little Spanish, and so mixed that Spanish with an English language shortened term for infectious mononucleosis: mono.

“Su hijo tiene el virus de mono”  which means to the parent: “Your child has the monkey virus,” which is pretty close to Monkeypox.

Early monkeypox presents with fever, fatigue, headache, and muscle aches, which is also the prodrome for COVID, infectious mononucleosis, influenza, and a hundred other illnesses so the lack of the characteristic rash is not sufficient to make a definitive diagnosis in the early stages.

Decades ago, Chevrolet had great difficulty selling a particular car model in Mexico and South America: the Nova. Nova in English is reminiscent of the French word for new, “nova” as in Nova Scotia. However in Spanish, “No va” means “no go” as in “the car that will not function.”

Providers with a little Spanish language capacity often have such miscommunications when they attempt to talk to their patients without a translator. They mix in English words, speaking Medical Spanglish.

Just as clinicians need to be precise and careful in their diagnostic process, this diagnostic information must be communicated to the patient in a way that they can fully understand, or the diagnostic process has failed. Communicating clearly with non-English speakers is a critical part of our professional responsibility as health care professionals.

For information on PHC provided video and telephonic interpreter services, see our website.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The search for a scapegoat is the easiest of all hunting expeditions.”
-Dwight D. Eisenhower

Part V in Series on Diagnostic Accuracy

Case Example: A 45 year old woman sends a secure electronic message to her primary care clinician, asking what she should do for her “heartburn.” Her PCP works a 3 day per week schedule at a chronically understaffed rural health center, and finally gets to the patient’s message at the end of a long day. The PCP does not ask any additional questions, but suggest the patient try OTC famotidine for a few days and call back if the “heartburn” is no better. Two days later, the PCP receives an electronically communicated consultation note from the local hospital, that the patient was admitted to the ICU in cardiogenic shock from a massive myocardial infarction. Glancing through the electronic health record, the clinician notes that the patient’s mother and father both died in their 40s of heart attacks.

This case of diagnostic error is certainly partly due to the PCP not performing an adequate assessment of the patient: not reviewing the electronic health record for background information, not asking additional questions to find out what the patient meant by “heartburn” or asking about red flag symptoms.

However, several system issues also contributed to the diagnostic errors: the overworked clinician, more prone to shortcuts to get through their day; the PCP’s reduced in-office schedule; the promotion of electronic communication to increase access to clinician; the lack of the PCP’s experience with rarer but more serious causes of “heartburn” because an emergency room/hospitalists sees all patients in the hospital.

The Institute of Medicine’s 2015 book “Improving Diagnosis in Health Care,” categorizes such system issues that contribute to diagnostic inaccuracy into five groups:

1. Organizational factors, such as schedules, staffing models, payer mix, and leadership.
2. Physical environment, including clinical ambiance, proximity to co-workers.
3. Tasks, which may compete for the attention of the clinician, like electronic medication refills, or which may not occur when they need to, like following up abnormal lab results.
4. Technologies and tools, such as the configuration of the electronic health record, and the use of electronic modalities for virtual care.
5. Diagnostic team members, including who is included on the team (adding a triage nurse for example), how communication occurs with the team, and the sense of responsibility team members feel to collaborate (in the case above, none of the physicians caring for the patient in the hospital called the PCP about the admission).

These same five factors contribute to clinician burnout and to health care inequities, so we as clinician leaders have a triple responsibility to spend our discretionary time working to steadily optimize this work system, the external environment that our clinicians work within. This is true for all clinician leaders, whether we work in primary care, specialty care, institutional settings like hospitals or skilled nursing facilities, at a health plan, or a government regulator.

At the same time, individual clinicians must continually strive to improve their own diagnostic processes, being aware of their own cognitive biases and short cuts, and reinforcing a sense of professional responsibility to achieve diagnostic excellence even with the shortcomings of the system we work in.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Listen with your eyes as well as your ears.”
-Graham Speechley

In the days before virtual visits and patients wearing masks, I would enter the exam room by greeting the patient, smiling and looking at them. So much information is communicated in this way. With our demeanor, we can convey caring, respect, and dignity. The patient, in turn, communicates mood, level of confidence, social/language/economic status, and (importantly) understanding.

My visits with patients are now either virtual (video or phone) or in-person with both provider and patient wearing a mask to prevent potential COVID transmission. This is affecting my ability to assess the patient’s mood and understanding, and makes it harder to quickly gain the trust of new patients.

Neuro-psychology experiments show that many human interactions (including social learning, empathy, and transfer of emotions) depend on the Mirror Neuron System of the brain. This system works best when a person experiences more complex sensory input. For example, a 2-dimensional view of a face on a video screen is less effective at influencing the Mirror Neuron System than an in-person interaction, where body posture, body motion, and context add meaning. The greater activation of the Mirror Neuron System when we are in the presence of others helps explain the excitement we now feel with interacting in-person with friends and colleagues, compared to previous video interactions.

The Mirror Neuron System also rapidly and unconsciously allows us to interpret the emotional state of others based on facial expressions. The eyes and the mouth are most expressive, so covering the mouth with a mask to prevent disease transmission decreases the information available to our Mirror Neuron System.

In many health care settings, routine mask wearing is still required. How can we make up for the loss of ability to see the facial expressions of the mouth? Interviews of women in countries where face coverings are common for religious reasons suggest three compensatory mechanisms that we can learn.

Eyes: First, learn to communicate emotion more effectively with our eyes. This takes a bit of practice. It requires us to spend a little more effort making eye contact and intentionality in connecting eye expression with emotional status.

Non-facial body language: Gait, character of a handshake, posture, and use of hand expressions can convey much emotional context. Clothing and grooming contain additional clues. These are difficult to see over video visits, but can be very helpful for in-person visits where the patient is masked.

Voice: Verbal expressiveness can convey information lost when visual cues are not present. This can be more subtle, depending on language concordance, personalities and habits of the clinician and their patient. I have seen a few clinicians who have remarkable natural capacity to strongly connect with patients, even on phone visits. Most of us can learn to master our greeting of patients on phone or video visits to build a sense of trust and empathy. As the clinician starts thinking about the differential diagnosis, options for testing, how many patients are waiting, and any personal stressors, our verbal expressiveness may lose some of its empathic quality.

For an excellent and very readable review of the many ways we communicate non-verbally, see The Power of Body Language, by Tonya Reiman.

For leaders and managers engaging with co-workers and community partners, these same compensatory mechanisms can be used for virtual interactions, but at a price. The level of engagement from virtual conferences and meetings is often significantly compromised, resulting in less interactive dialogue, less productive debate, and less synergistic learning. In particular, partners and policymakers are not cooperating and solving problems as effectively. To overcome this, we must strive to leverage in-person interactions. If infection safety is a concern, we can meet outdoors (particularly good for meetings with a meal) or in a well ventilated indoor setting with sufficient distance to minimize risk of airborne infection but close enough to see each other’s expressions and body language. Judicious use of rapid COVID antigen tests also has a role.

This is our new normal. We owe it to our patients, our organizations and ourselves to put our Mirror Neuron Systems back to work.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sail.”

-John Maxwell

The COVID pandemic was a storm that caused not only loss of life and disability, but tremendous lasting stress to the health care delivery and public health systems. Since March, the storm is settling down, and we seem to be beginning a prolonged recovery phase. Staffing shortages, financial stresses, and anxiety about COVID, the economy and world events are major headwinds to this recovery. These headwinds are diverting leadership energy away from collaboration, innovation, and quality improvement activities.

It is possible to move forward against headwinds. Sailboats do this by trimming their sails, and carefully navigating their boat to a heading as close as possible to directly into the wind, and then changing tack periodically so that the net movement can be directly into the wind. The skipper (leader) needs to pay close attention to the wind, communicating quickly with a crew that knows they need to work together to achieve their goal.

Mastering the headwinds

As clinical leaders, I hope you are in a phase in this pandemic recovery in which you can trim the sails, and refocus your teams on moving forward with performance improvement and collaboration activities. Our teams at Partnership HealthPlan of California (PHC) are here to support you in this effort.