Citizen Health Care Role Called Critical

By ALEXIS TONTI

If the Island wants better health care, its citizens must demand it.

This simple but straightforward directive was one of the chief messages of the second annual public symposium, Changing Our Health Care: Options for the Vineyard, held Sunday night at the Performing Arts Center.

"The system is yours," said Dr. Donald Berwick, president and CEO of the Institute for Healthcare Improvement. "The community has the right to help shape it, give input. This is not combat; this is dialogue."

The audience of nearly 175 took that advice to heart during the two-hour panel discussion sponsored by the Dukes County Health Council, the Foundation for Island Health and Healthy Communities Martha's Vineyard. The panel included Mr. Berwick, who is also a clinical professor of pediatrics and health care policy at Harvard Medical School; John Ferguson, president and CEO of the Hackensack University Medical Center and chairman of the board of trustees of Martha's Vineyard Hospital; Dr. Ilene J. Klein, a family practice physician on the Island, and Cynthia Mitchell, director of the Island Health Plan.

Moderator Mike Wallace, Tisbury seasonal resident and host of the CBS news program 60 Minutes, fielded a steady stream of questions and posed some of his own. Throughout the dialogue, one idea emerged again and again: developing a community-based health care system, with health practitioners working cooperatively rather than independently to service the needs of the Island.

By evening's end the first step was taken, with a commitment by panelists to hold a series of workshop retreats where health care practitioners could discuss redesigning the Island health care system.

In his opening remarks, Mr. Wallace called the evening an exploration, a venue to talk about "what we need to do to make sure all of us have access to the best health care a forward-looking Island can provide."

To begin, Mr. Berwick gave a brief presentation on health care in America and targeted areas for improvement. The Vineyard, he stressed, is not alone in its grappling with health care. It is an issue faced by the entire country, though solutions must be considered within the special context of one's environment. In particular, he said, the Island needs two systems in place: one for the year-round population and one to accommodate the influx of people that comes with summer.

The key change, Mr. Berwick said, needs to be made in quality of care. "Quality is a system property," he said. "When a failure occurs, it is a failure of design, not of the people" who work in the system.

So how to improve the system? The first step, he said, is simply to make the decision to improve. He named six areas to focus on: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. He suggested that the Island develop a measurement system to track progress and to review that progress annually.

Change must then come to the way the care is designed. For example, utilizing the Internet as a resource; e-mailing doctors as an alternative to office visits; establishing Islandwide protocols for treatment, and shifting to a team approach for patient treatment.

Third is to address the way organizations deliver that care. Ideally, Mr. Berwick said, an Islandwide information infrastructure would be developed to allow for the sharing of information between physicians; electronic patient records could be used, providing the most complete picture of a patient's medical history and current condition. He also suggested an Islandwide employee training scheme that would result in uniform patient care.

The suggestions were a lot to digest, but the practical application of Mr. Berwick's ideas slowly took shape when the question and answer period began. The panelists talked about the progress that's already under way and shared their visions for the future.

Mr. Ferguson began by speaking to the ongoing improvement efforts at the hospital, which include a master program and facility evaluation. He said they're looking at medical specialties to decide which areas need an expanded or reduced staff. For example, with an increasing population of retirees, a geriatric physician might be a necessary addition.

But, as Ms. Klein pointed out, "The hospital is only part of the continuum of health care. We need to think about prevention and primary care. We have to move forward toward a continuous, comprehensive health care center, a collaboration of physicians working together to keep the Island healthy."

The group care to which she referred became a theme for the evening. As explained by Mr. Berwick, group care in this context means "physicians who jointly share the responsibility for meeting the needs of the Island." To do this effectively, health care practitioners could use standardized medical records and establish Islandwide care protocols to ensure uniform treatment. They also could implement an information infrastructure, accessible to all, to help protect the health of patients - for example, it would provide a way to check for possible drug interactions when prescribing medication.

How to pay for such a system is a natural concern. Ms. Mitchell said it's possible to receive funding as a result of federal designations (the Island has already been named a health professional shortage area, she said, and thus receives "higher reimbursements from the powers that be"). Also, in her work with the Island Health Plan, she has been working on a new Island health insurance policy that would bring in money.

Mr. Berwick added to the subject of financial feasibility by discussing ways to save money. Office visits are often unnecessary, he said, and no more than requests for information. Such visits could be eliminated by using e-mail to correspond with doctors and by improving self-care - that is, teaching patients with chronic conditions such as diabetes and asthma to manage and monitor themselves more reliably.

Ms. Klein said she has begun to experiment with the use of e-mail in her own practice. She said patients seem to appreciate having the option, but whether it proves worthwhile in the long run remains to be seen.

What will make a community-based health care system a reality, said Mr. Berwick, is leadership. But as Ms. Klein pointed out, there might not have to be only one leader. The Island, she said, already has several key organizations asking themselves the same questions and considering similar solutions, the Dukes County Health Council, Martha's Vineyard Community Services, the Foundation for Island Health and the hospital among them. "They all want to make the system better, and we are all struggling," she said. "We need time to focus."

Her comment led to Mr. Berwick's suggestion to schedule a series of health care redesign workshops. "You don't get change for free," he reminded them. "You have to be willing to invest."

It was an investment the group was willing to make, with the panelists agreeing to do just that, and with Dr. Charles Silberstein, Island psychiatrist and Foundation for Island Health chairman, even coming to the microphone to voice his support for the idea.

In remarks that ended the evening, Mr. Silberstein said, "We can make this the best rural health system in America. And it's not just the hospital anymore - it's so much more than that."