Time Out! How Strategic Pauses Can Enhance Medical Decision-Making to Improve Outcomes 

Health care providers are under increasing pressure to improve outcomes for patients with chronic conditions. There is pressure to meet quality measures, to establish programs that improve outcomes, to decrease costs for these conditions (utilization as an outcome)—or a combination of goals. At issue: what works, what is affordable, what is acceptable to patients and clinicians.

The answers are elusive because there are many factors involved in the care of patients who have numerous chronic conditions, co-morbidities and medications, as well as multiple healthcare professionals providing their care. Adding to this complexity, any outcomes improvement for patients with chronic conditions often depends on their making lifestyle changes that are not always within their control (e.g. homelessness, food insecurity, isolation).

Typically, office management of chronic conditions involves an ebb and flow between results (tests, physical findings, patient feedback) and therapeutic interventions (medications, lifestyle modifications). This focus may cause the clinician to overlook important changes in the patient’s situation. The patient may have experienced a dramatic change in living conditions (if, indeed, they still have a home) or may have lost faith in their treatment plan. It’s necessary to regularly “step back “ and review everything about the patient, treatment assumptions, and results of the care plan. This approach is particularly important when provider and/or patient cannot control outcomes or when the patient’s health is declining.

For all these reasons, providers—and patients—would be well served by “strategic pauses” in the management of chronic conditions. At key junctures, when outcomes hang in the balance, clinicians and patients should review and reflect on the patient’s overall status and care plan.

Strategic Pauses Are Well-Established Medical Decision-Making Practice

This is not a new concept. For example, the World Health Organization surgical operative checklist details what must occur before the induction of anesthesia (confirmation of the patient’s identity and the nature and site of the procedure); before skin incision (confirmation of all team members’ roles, review of critical or unexpected surgical steps, antibiotic prophylaxis administration); before the patient leaves the operating room (key concerns for recovery, proper labeling of specimens). This checklist is akin to the pre-flight checklist used by airline pilots.

Another example of pausing and checking, one that should occur at all office visits (and is, indeed, a quality measure), is medication reconciliation. This potentially life-saving step helps to prevent duplicate prescriptions from multiple clinicians and serves to confirm for both patient and clinician all medications and other agents, such as herbal or OTC drugs, which a patient is taking.

How Strategic Pauses Apply to Treatment of Chronic Hypertension

Let’s take a closer look at how a strategic pause could improve the care of a patient with hypertension. This involves four basic steps:

Step 1: Confirm the diagnosis.

The diagnosis of hypertension has changed significantly in the past year, given a revised definition with a lower threshold. Formerly defined as ≥140/90 (systolic blood pressure/diastolic blood pressure), hypertension is now diagnosed as ≥130/80. As a result, the prevalence of hypertension has increased from 32 to 46 percent among adult Americans. Accompanying this shift are changes in recommended therapy for selected patients with lower blood pressure levels, as well as more aggressive therapy for many patients.

Step 2: Confirm the results (blood pressure readings).

How blood pressure is taken merits scrutiny; a number of factors may influence results. Standards are very rarely followed, as they are time consuming and not widely known. Most of the resulting errors contribute to a falsely elevated reading. If a clinician relies exclusively on office blood pressures, she may over-treat or under-treat the patient:

• 35 percent of people with elevated office blood pressures may have normal blood pressure readings when measured outside of the office (white-coat hypertension);
• 30 percent of patients with non-hypertensive office blood pressure readings have elevated readings out of the office.

Antihypertensive therapy can lead to orthostatic hypotension, mainly in the elderly. Measuring standing blood pressures in older patients receiving antihypertensive medications may help identify patients at risk for falls. In my experience, this is rarely done. Triggers for such a measurement include postural symptoms, light-headedness or faintness on standing; but patients are often not queried about such symptoms. Taking the time to confirm results and do additional blood pressure readings, as needed, can avert potential complications.

Step 3: Detect hidden risks.

Factors such as unhealthy alcohol consumption can contribute to hypertension (in the United States, alcohol may contribute to 10 percent of the population burden of hypertension). Identifying occult alcoholism is an important task and well worth a clinician’s attention.

Step 4: Determine factors within the patient’s control that can improve outcomes.

Lifestyle issues are key to managing hypertension. A healthy diet and regular exercise can dramatically lower blood pressure. Assessing whether the patient understands the benefits of lifestyle changes and is willing to make these changes is essential. Managing hypertension is often up to the patient; the clinician has a critical role to play in educating and supporting the patient, as well as goal-setting. All clinicians caring for the patient should know the patient’s important personal goals, outcomes and acceptable risks. Clinicians should also be aware of major changes in the patient’s life circumstances, such as loss of home, family or friend.

Controlling blood pressure also requires that the patient reliably take antihypertensive medications. Patients may feel ashamed about not regularly taking their medications; clinicians are well-advised to make time to discuss how this might occur, exploring issues of cost and side-effect barriers. The new hypertension guidelines call for two medications from different classes for patients with a blood pressure of ≥140 (systolic) or ≥90 (diastolic), adding to the therapeutic complexity. Some side effects, such as erectile dysfunction, are embarrassing, but require discussion within a trusting clinical relationship. Reviewing the patient’s beliefs on the treatment plan is an ongoing need.  Patients won’t take medications if they don’t believe they work. This is especially true for hypertension, which is largely asymptomatic until the devastating consequences of uncontrolled hypertension become all too apparent.

Strategic Pauses Require Organizational Leadership and Resources To Succeed

For individual physicians and practices, implementing a systematic process of strategic pauses may not be feasible, due to limited time and resources. Healthcare organizations, by contrast, have a greater capacity for such an initiative and can bring more resources to bear. By systematically identifying patients who are not improving, validating all the assumptions of their diagnoses and treatment modalities, and testing interventions that may be more fruitful, providers can enhance quality measurement and improve performance.

For organizations competing against one another for optimal cost and quality scores under MACRA MIPS, or for those under pressure to maintain attributed patients under Alternative Payment Models (APMs) such as ACOs, quality measurement of outcomes will become increasingly important. The impact of strategic pauses, when included in a performance improvement project, may be measured and compared by evaluating outcomes over time along with cost. This requires focused technology, such as a Qualified Clinical Data Registry’s capacity to track individual patient outcomes as well as test the results of various interventions like strategic pauses.

Among the activities that organizations should finance and standardize:

• Identification of patients whose outcomes did not improve, or whose cost profiles indicate repetitive crisis points or testing patterns. Establishing criteria for patients who may be candidates for strategic pauses will help to control volume and better align potential benefit for the practice.
• Patient outreach to bring them back into the process, through a centralized mechanism.
• Development of patient criteria for the program and for creation of goals, targets and measurements.
• Training or protocols to reduce the potential for inaccurate outcomes measurement, such as standardized blood pressure readings.

By implementing strategic pauses through a Performance Improvement Activity (PIA) under MACRA MIPS, health care organizations will reap financial benefits by increasing the scored points associated with PIAs. Even more significantly, they will improve other quality cost performance scores, potentially tipping the organization into eligibility for an incentive.

Identifying patients for this program via system-wide data will allow for a more focused approach. The greatest value in treating hypertension is lowering extremely high blood pressures. Patients whose conditions are out-of-control or quickly worsening should be the initial targets.

Six Steps to Ensure the Success of Strategic Pause Performance Improvement Activity

While strategic pauses may offer a very promising opportunity for performance improvement, success will hinge on including clinicians in the process of program design, rather than overwhelming them with new requirements. These six areas can raise the chances of successful implementation and results:

1. Start with a small number of patients who are most at risk.

Patients whose hypertension is out of control or strongly trending toward higher blood pressures, particularly those with a high risk of cardiovascular events, should be selected for strategic pauses. Most practices have limited resources, and the focus should be on who might benefit the most.

2. Prepare the patient by capturing information prior to the office visit.

Here is where a structured phone call to the patient is valuable. Match questions to the patient with a template in the EHR. Develop and follow a script. Suggest that the patient might consider bringing a spouse, relative or other trusted individual to the visit. This sets the stage for greater understanding and strengthens the patient’s social support.

3. Be aware of the “tyranny of the urgent” in the office.

When discussing any changes or additions to their routine office work flow, primary care physicians repeatedly tell me, “I can’t take the time to do anything more.” This is a major challenge. These physicians are under significant time pressure, and productivity (upon which much of their revenue is derived) favors addressing acute or urgent problems. To successfully implement strategic pauses, move gradually and track steps taken. Integration into the existing workflow is essential. These strategic pauses are not a big, one-time event, but, rather, a culture shift.

4. Engage the patient’s support system.

Clinicians need to know whom the patient trusts to share his or her health journey. Identify this individual (or individuals), maintain records and track any changes. Understand how much the patient wants the health care team to include this individual in any discussions and medical decisions.

5. Sustain patient motivation and belief.

It will be critical to maintain contact with the patient over time and to identify barriers to care as they arise. Teach the patient to self-measure blood pressures properly and consistently; he or she will take a more active role and can see the results of therapy directly.

6. Change the strategic pauses based on observed outcomes.

For the patient with chronic hypertension, how has health status changed (if at all) with any change in blood pressure readings?  Assessing how strategic pauses have played a role in these changes will illuminate their impact. Capture feedback from patients and clinicians about the strategic pauses and note where successes or failures occurred.

As stated above, successful implementation of strategic pauses should be incremental, part of a broader process that includes measurement of outcomes and ongoing evaluation. This process should increase the central role of the patient in medical decision-making.

Strategic Pauses Are Part of An Expanded VBHC Concept of Medical Decision-Making

Value-Based Health Care (VBHC) has begun to create an awareness among providers that we can no longer continue to accept poor patient outcomes as satisfactory, and that providers must engage in a continued process of questioning and engaging toward improved results.  But individual physicians and practices have neither the time nor other resources to establish processes required by the transition to value.

Obtaining an improvement in patient outcomes must occur through correcting diagnostic error as well as encouraging patients to modify lifestyles and to overcome their barriers to treatment. It is a notoriously difficult task that will demand a new medical decision-making process in which both the physician and the patient, and the patient’s support system, must participate.

Strategic pauses and Shared Decision-Making are two tools that affect medical decision-making with much in common. Both involve validating and questioning the patient’s symptoms, diagnosis, barriers, and belief systems. Both involve clinicians’ willingness to modify their approach to reach joint goals with the patient. And both approaches will require an investment of organizational resources to help clinicians be effective and measure improvement.

Organizations may now be sufficiently motivated to employ strategic pauses and other aspects of a revised Medical Decision-Making approach.  Doing so, especially by generating processes that engage patients and their support system, promises to strengthen clinicians’ relationships with patients—key to building consumer loyalty—as well as produce better results.

Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.

Image Credit: Johan Desaeyere