Health care professionals (HCPs, that includes dentists, nurses, pharmacists, physicians and physician assistants among others) receive too little support in changing their practices, processes and policies to improve the health of their patients. In many cases they are simply given clinical recommendations to follow and are viewed as passive ‘channels’ to provide ‘authoritative and credible’ information to their patients.
I talked about this as a ‘swamped channel’ in Pediatricians Drowning in Advice and noted a study that documented 162 separate pieces of verbal advice pediatricians are recommended to provide their patients by policies established by their professional association. And then there are the hundreds (thousands?) of ‘tools’ that are distributed to HCPs to guide diagnosis and treatment decisions, counseling aids (including numerous ‘shared decision-making tools’ that include the patient and family in the process), and legal requirements such as for ‘meaningful use’ of electronic health records (EHRs). Diffusing information, products and services to HCPs is a symptom of the producer orientation (or top-down perspective if you like): the expectation is that if HCPs are given these guidelines, tools and incentives, they will use them. Time and time again we see this is not the case. For example, estimates are that between 18-37% of US health spending is wasted. Wasted health care payments include those due to failures of care delivery - poor execution or lack of widespread adoption of best practices, such as effective preventive care practices or patient safety best practices; overtreatment, or care that is driven by providers' preferences, ignores scientific findings, and is motivated by something other than providing optimal care for a patient; and costs incurred while treating avoidable medical injuries, such as preventable infections in hospitals (Lallemand, 13 December 2012, “Reducing waste in health care,” Health Affairs). Better dissemination of ‘best practices’ is often called on to address these sources of ineffectiveness, inefficiency and waste in health care. In reality, adoption and sustained use of best practices is what is needed. How do we develop fewer expert-driven recommendations and more market and user-focused approaches to better practice? This is the type of puzzle that social marketing could be used more frequently to solve (see Chapter 13 - Social marketing for diffusion and program sustainability, Lefebvre, 2013, and Harris et al, 2012, A Framework for Disseminating Evidence-Based Health Promotion Practices in Preventing Chronic Disease).
It was from this perspective that I agreed to chair a session on “How to reach professional audiences,” knowing full well that ‘reach’ is not the problem. While each of the three presentations in the session provided useful information (you will find links to their abstracts through the last page link), they focused on conducting formative research and developing more toolkits for physicians. I had read these papers before the conference and was ready to exercise the chair’s perogative to make some comments at the end of their presentations. Here are some of the points I made and that you might consider when the subject of prioritizing HCPs or conducting outreach to them comes up in your program planning meetings.
Improving HCP Practices
No HCP group, whether it is physicians (even within a specialty area) or pharmacists, is monolithic. Segmenting them into more homogeneous groups is what allows you to tailor programs that are more relevant and useful for them. Segmentation might be done by practice setting, size of the practice, geographic location, HCP age, early adopter status and peer influencer role for starters.
HCPs have very few ‘needs;” they do, however have many problems to solve and jobs-to-be-done on a daily basis. Developing tools that help them solve these problems - not just the one we pick - is the next step.
How we help them integrate new practices into their existing work flow and office systems has been shown time-and-time again to be an important determinant of adoption. When adopting new practices require changes in work flow or office systems (adoption and meaningful use of EHRs is an example) we need to provide them with support products and services - and sometimes incentives - to divert their time and attention away from patients as briefly and efficiently as possible.
The immediate opportunity costs for adopting new practices (for example, fewer patients being seen) is a big issue for many HCPs I have worked with over the years. Stressing the longer-term benefits of adoption is not the answer. What are their most important jobs-to-be-done everyday and how do we help them get them done? That is the first question we need to be asking HCPs. What will be news to the neophytes to this world of HCPs: patient care is not usually at the top of these lists. The top of the list usually includes financial matters (especially in the US and in private sector practices) and satisfying bureaucratic demands.
Engaging some HCPs to be co-producers of products and services we want to offer to their peers is another step in the process that too few programs implement. And by this engagement, I don’t mean the convening of expert work groups who contrive ways to push guidelines and evidence-based practices onto their less expert peers. Rather, it is through attracting the real users, the HCPs who are in practice and have a much more informed perspective on the jobs-to-be-done in their everyday professional lives, that we can begin to design ways to adopt new practice behaviors, use decision-making tools and toolkits, and change their office systems and processes that also enhance their ability to get things done (or at least not get in the way of their getting done).
If you have done everything on this list so far, you may have developed some empathy for HCPs. Overcoming the stereotypes we have of different HCPs (What is a pharmacist’s daily job really like? How hard is it to be a physician’s assistant?) opens up the possibility that we can work with them to improve what they do - not just try and persuade them, or incentivize them, to do what we want them to. We can begin to imagine adoption experiences for them in which they find value. I always think of the 162 pieces of advice pediatricians are already suppose to give their patients whenever I am in a meeting with people discussing HCP programs and someone suggests “Let’s get physicians (or any other HCP) to tell their patients about (or, do)…!” It sounds benign and simple, but is has become insidious strategy that reflects little empathy for the HCP. Programs that employ that strategy simply add to the swamp.
Another tactical decision that reflects this lack of understanding and empathy is the one where program planners decide that one HCP group should be referring their patients to another one - usually this involves saying to general practice physicians to refer certain patients to specialists (for whatever expert-guided or evidence-based reasons). Referral in all of these instances isn’t a signal of better practice, it is a cue for the primary HCP to fear losing control over patient care - not something they find any value or benefit in doing. For example, a recent analysis of barriers to referral for genetic services, a fast developing specialty area, found not only HCP knowledge and practice deficits, but the concern about ‘coordination of care.' If you were to address such a set of problems, where would you begin?
Finally, and most importantly, HCPs are people too: this is where the crowd at the session applauded. Applause is a funny way to respond to the obvious, but it is making the obvious a social norm that is important to people who work in this area. HCPs are not, as the experts might wish, automatons do be directed or functional units to be dissembled and reassembled to perform new tasks more effectively and efficiently. Neither do they want to be cajoled into change or otherwise manipulated. Yes, there are the exceptions, but the majority of HCPs, whatever their title, are smart people, doing tough work under difficult circumstances. People who respect their intelligence and ability to make responsible decisions, and offer ways for them to do their jobs better, are met with open hearts and minds. The rest of you are just noise.
Further Reading on Diffusion and Health Care
Damschroeder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A. & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Science; 4:50 doi:10.1186/1748-5908-4-50
Abstract: We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts. The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect).
Greenhalgh, T., Robert, G., Macfarmane, F., Bate, P. & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly; 82:581-629.
Abstract: This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.
Keown, O.P., Parston, G., Patel, H., Rennie, F., Saoud, F., Al Kuwari, H. & Darzi, A. (2014). Lessons from eight countries on diffusing innovation in health care. Health Affairs; 33:1516-1522.
Abstract: This article describes the results of a qualitative and quantitative study to assess the factors and behaviors that foster the adoption of health care innovation in eight countries: Australia, Brazil, England, India, Qatar, South Africa, Spain, and the United States. It describes the front-line cultural dynamics that must be fostered to achieve cost-effective and high-impact transformation of health care, and it argues that there is a necessity for greater focus on vital, yet currently underused, organizational action to support the adoption of innovation.