When we speak of ideal health care that we want to receive or that providers aim to deliver, the phrase that jumps to mind is: “the right care, the right place, the right time.” This phrase in this context is so ubiquitous that tracing its origin is nearly impossible, but it does roll off the tongue easily and captures the concept accurately. Perhaps because of how easy it is to say and remember, the difficulty of actually delivering care that meets this standard has been trivialized by those who do not actually provide health care.
To deconstruct how ideal care could be delivered, let’s use the example of an individual’s office visit with a physician. Whether the purpose of the visit is health maintenance or acute illness, to deliver the “right care,” the physician needs to (at a minimum) access all pertinent historical information, glean any new insights through questioning, and understand what the patient wants from the encounter. Using all of these sources of information, the physician establishes the patient’s specific diagnosis and/or preventive-care needs, applies the best practice for the situation, communicates the actions to the patient and voilà—the “right care.” With the enormous complexity of each step in this process, it is amazing how frequently the physician acting on his/her own actually does get it right. Now, add in the expectation that the “right care” needs to be delivered every time and something has to change.
Delivering care at the “right place” is no less daunting a task. Consider in our example that best practice dictates the patient be sent for a cardiology consultation. What type of cardiologist is most appropriate: a general cardiologist, one that specializes in arrhythmias, or another in congestive heart failure? Once that is established, which specific individual cardiologist should be consulted? To provide the care in the “right place,” this decision should ideally be driven by matching the patient’s needs with the cardiologist who can deliver the “right care” and do it most effectively and efficiently. Empiric data are usually not available to guide this decision, and the referring physician often relies on social or business factors. It may be as idiosyncratic as selecting the cardiologist who has a child on the same soccer team as the referrer’s child.
And, what is so difficult about delivering care at the “right time?” One need go no further than the example of providing age-appropriate preventive care to answer this question. Most primary care offices do not have good systems to identify a patient’s health-maintenance needs and to proactively and consistently arrange for delivery of those services. The backup is for the individual to know what they need and proactively contact the physician’s office to schedule needed services. We all know how easy it is to reach out to have that colonoscopy scheduled without prodding, right? An ounce of prevention is truly worth a pound of cure, and having preventive services provided at the “right time” is clearly best for the individual and the public good. Yet, this is currently impossible to accomplish every time.
As a physician, I have provided care in a rural primary care clinic and in a large academic specialty practice. In every patient encounter over the years, I have attempted to deliver the right care at the right place at the right time. I hope I have accomplished this a significant proportion of the time, but I’m absolutely certain that I have not met this goal close to every time. To make consistent delivery of ideal care a reality, systems and tools must be put in place to support the provider-patient interaction—systems which provide agreed-upon protocols for care, background on the expertise and efficiency of consultants, information systems that make available health information for individuals and providers, and direct linkages between different service sites, just to mention a few required elements. To independently build the systems necessary to support the patient-provider encounter at every site of service would be way too costly, and quality would be compromised by the handoffs from site to site, system to system. The answer lies in networks of providers coming together to jointly develop and share common support systems and tools. That’s just what we are doing through the UVM Health Network and OneCare Vermont. With the collective participation of all our providers, we can achieve the ideal of providing the right care in the right place at the right time . . . every time.
John Brumsted, MD, CEO, The University of Vermont Medical Center and The University of Vermont Health Network.