Best Practices: Restructuring Health Care Practice

The progress of the information revolution in clinical health care has been slow compared with its advance in fields such as financial services, manufacturing, architectural design, and transportation. Computerized data processing came first to the financial aspects of health care, including clinical billing systems. Clinical laboratories, radiology, and research absorbed the new and powerful tools made possible by computer technology. Clinicians were dragged reluctantly into compliance with diagnostic-related groups (DRGs) and Current Procedural Terminology (CPT). Reluctance was followed by dismay when use of DRGs and CPT led to the creation of massive pooled databases of clinical information and the documentation of significant variations in quality, cost, efficiency, and outcomes.

Managed care, chosen by the financial sponsors of health care to reduce those variations, led to the loss of the individual practitioner's autonomy, power, and prestige. The current absurd conditions of clinician irritability and litigiousness as well as the ineffective corporate turmoil of managed care must be temporary. But what comes next? What will be the structure of future clinical practice? How do we conscientiously, persistently, and systematically attend to what we can do to alleviate the suffering and pain of the individuals with mental and emotional disorders who seek our services? How do we turn our attention from the governance and finance of health care to the meticulous and compassionate provision of health care?

Many of our fundamental belief systems have been superseded by evolutionary changes in culture, technology, and science. No one alive today is spared the necessity of making paradigmatic adaptive changes in behavior, beliefs, and belongings. The demands of information science force us to relinquish cherished and deeply personal investments in professional disciplines and in the hierarchy of those disciplines.

Many clinicians are individually, quietly, successfully, and without guilt or grief changing their day-to-day professional behavior. But collectively, our organizations, meetings, and many of our publications reflect only the ongoing legalistic warfare with managed care and sometimes with each other. Many of us informally express a cloying sense of self-righteousness about our humanism and altruism, in contrast to the crass commercialism of those who insist on showing a profit on the bottom line. Thus we denigrate the market forces and processes that played a crucial role in the development of our civilization and have continuously supported the social structure since the dawn of democratized society.

Surely we can reformulate new shared missions and collective goals for our many clinical disciplines. The principles are clear. First, best-practice procedures must be continuously updated based on the best science available and must be delivered through humane and compassionate relationships with our patients. Second, we must submit to, or, better, we must embrace tests of efficacy and demands for effectiveness in the same manner as does any other major enterprise. Third, we should value efficiency as much as we do compassion and empathy if we expect to be paid for our efforts with public or semipublic funds. Fourth and finally, we should incorporate in our practice an awareness of the costs of our services on both an individual and a societal scale.

Future clinical practice will undoubtedly embody these standards and values, but I am concerned about the manner by which we will arrive at that point. Will we evolve to that point at least partly through our own efforts and in our own style, or will we be forced by the stressful, stringent, competitive forces of the market economy to go there struggling and kicking all the way? At this time, market forces seem to be driving and guiding our destiny.

Each of these four facets of our common goal will require intensive and extensive discussion and exploratory implementation. But we desperately need some vehicle, model protocol, or set of procedures or algorithms for describing and documenting our specific services while embodying the four transactional elements. In the mid-1980s, when clinicians were learning how to use such unpleasant but necessary words as "marketing," "cost," "profit," and "business," I introduced a proposal through the council on economic affairs of the American Psychiatric Association that we should seriously consider reformulating psychiatric practice from a process-oriented, totally individualized endeavor paid for by the hour to a procedure-structured effort paid for according to the intellectual or informational content, level of work effort, or practice expense of the procedure. The proposed structure was described in The Catalogue of Psychiatric Procedures, published in 1988 by the American Academy of Child and Adolescent Psychiatry (1). This proposal was culturally and politically premature and is now outdated.

Meanwhile, the CPT manual published and promoted by the American Medical Association (AMA) has become the required standard. It is accepted by the Health Care Financing Administration, Medicare, Medicaid, most insurance companies, and many managed care organizations. The determined and dedicated work of APA members Chester Schmidt and Tracy Gordy has helped the AMA's CPT committee come to a fair inclusion of psychiatric work within the generic procedural terminology of the CPT. In the early 1980s I strongly criticized the CPT. Those opinions have been replaced by a grudging admiration for the efficiency and inclusiveness of this system and for the acceptance, though frequently reluctant, accorded to the CPT by most physicians, psychiatrists, and nonmedical clinicians and by government agencies and the insurance industry.

But the CPT functions solely as a universal payment system. It documents generic procedures in a way that is almost devoid of information that would structure and then resolve crucial and complicated issues in many clinical decision trees. The CPT makes no contribution to organizing or codifying the body of knowledge, information, or skills that make up the clinical practice of psychiatry, mental health, or to use the newer, trendier term, behavioral health. In addition, the CPT does not provide a framework for developing a curriculum for education of clinicians. Nor does it provide a means for each clinician to monitor the quality and confirm the validity of his or her own work. Further, the CPT does not provide a vehicle for sharing structured information in an integrated record system or for providing necessary information to patients, clients, or consumers and their families so they can participate as fully as possible in the health care decisions.

Could a complete set of practice guidelines provide a knowledge base to complement CPT procedures? Perhaps this complementary relationship may eventually be developed. However, at present, despite the meritorious work of the organizations and individuals who have developed practice guidelines, they have not risen above the quality of excellent textbook or journal reviews. Current guidelines lack the precise structure of sequential, parallel, and optional decision trees that should provide the best known paths from symptoms, signs, and problems through diagnostic categories and conditions to treatment interventions.

Of course, many clinicians and academicians are opposed to any attempt to systematize the body of knowledge of clinical psychiatry and codify it in a set of procedures, protocols, or algorithms. Is this position more likely to be held by psychiatrists trained in a less disciplined style of mental habit or by those who are deeply disciplined and perhaps unconsciously committed to the residual beliefs of an earlier culture of practice? Perhaps only psychiatrists who have been shaped by the culture of the information sciences are comfortable admitting what we don't know as well as defining what we do know as we attempt to heal the sick and to comfort the suffering.

Presumably we must start with the careful, practical, and timely application of research findings. However, we have not had outstanding success bridging the gap between research and everyday clinical practice. Similarly, experienced and insightful clinicians have not been successful in providing researchers with information about the enormous variety of technical and human problems and decisions faced daily in the trenches of the practice of psychiatry and behavioral health care.

In fact, many if not most of the decisions made in daily practice will never be subject to rigorous research protocols. Nor can government, institutions, managed care or professional organizations, or even a supervisor provide much more than a general structure, a disciplined attitude, an ethical framework, and fairly balanced financial and humanistic incentives. The actual practice of medicine and the allied disciplines has always been a personal, even private, individual or small-team creative activity, taking place within a limited set of relationships. This characteristic of practice is not likely to change, despite the legal and financial constraints that are currently causing a sense of despair and loss of morale.

Half of the multi-interleaved problem is how to provide the individual clinician with guidelines or algorithms that can structure the diagnostic and treatment interventions necessary for best practice. The other half is how to stimulate and encourage the individual clinician to assume responsibility for implementing these guidelines and for providing the necessary artistic elements of practice derived from education, motivation, experience, skills, and compassion. Best practice will be the seamless amalgam of these separate efforts and will be the most complex set of professional procedures any society has ever produced.