Friday, November 11, 2016

Accomplishing the Triple Aim while Addressing the Triple Shames

FLASHBACK SERIES: Blog posts written during my medical school days at Pacific Northwest University - College of Osteopathic Medicine

by Kim Ha Wadsworth, OMS III
Primary Care Core rotation (Family Medicine 702)
Preceptor: Dr. H. Matt Smith - Kennewick, WA
November 11, 2016

Despite US healthcare spending that is more than twice the average of other developed countries (Fig. 1), the life expectancy in the United States is the lowest of the developed world (Fig. 2). Moreover, according to a recent study by researchers at Johns Hopkins Medicine, medical error is the third leading cause of death in the US.1

Figure 1. United States per capita healthcare spending is more than twice the average of other developed countries. Reprinted from Peter G. Peterson Foundation website. Retrieved October 22, 2016, from http://www.pgpf.org/chart-archive/0006_health-care-oecd. Copyright 2016 by Peter G. Peterson Foundation.

Figure 2. Link between health spending and life expectancy: US is an outlier. Reprinted from Our World in Data website. Retrieved October 22, 2016, from https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus. Copyright 2016 by Max Roser. Reprinted with permission under CC BY-SA.

Given these “triple shames,” the Institute for Healthcare Improvement (IHI) developed a new framework—the Triple Aim—to optimize health system performance. The Triple Aim was first introduced in 2008 by Drs. Don Berwick, Tom Nolan, and John Whittington of IHI to enhance patient experience (including quality and patient satisfaction), improve population health, and reduce the cost of health care.2 More recently, Drs.Thomas Bodenheimer of UCSF-SOM and Christine Sinsky of AMA recommended that “the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.”3 Indeed, the importance of this fourth component is highlighted in a recent New England Journal of Medicine article,4 which discusses how physicians’ inability to tolerate uncertainty contributes to stress, burnout and escalating health cost due to excessive ordering of tests, iatrogenic injuries and diagnostic errors.

As I considered how to accomplish the Triple (Quadruple) Aim while addressing the triple shames, I explored innovative models of care that have proven, effective methods for improved health outcomes.
  • Shared Medical Appointments (SMAs), endorsed by the American Academy of Family Physicians,5 are clinician-led group visits involving medical intervention in addition to an educational component. They are typically utilized for follow-up care or management of chronic conditions. SMAs improve quality, access, productivity, outcomes and patient / physician satisfaction while decreasing cost. In particular, for providers, repetition of the same information is minimized in a group format and no shows / late cancels have less impact.
  • Primary Care Medical Home (PCMH, aka: patient-centered medical home, advanced primary care, and healthcare home) is described by the Agency for Healthcare Research and Quality as transforming the organization and delivery of primary care to improve the quality, safety, efficiency, and effectiveness of health care by focusing on prevention, wellness, acute care, and chronic care in a team-based, interprofessional practice.6 The PCMH model encompasses five attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and service.
  • Telemedicine is a key to the future of medicine, expanding from its original purpose of reaching remote patients living in rural areas to its increasing use today as a tool for convenient medical care. The American College of Physicians published guidelines in 2015 for the use of telemedicine in the primary care setting, recognizing telemedicine’s rapid growth and its potential to “expand access for patients, enhance patient–physician collaboration, improve health outcomes, and reduce medical costs.”7 It is also interesting to note that, as more patients use mobile health apps and mobile medical devices to monitor their own health, demand will increase for alternative ways to get care, such as through telemedicine.
These models can transform health care in the 21st century, but I will not ignore other simple tools and best practices that I have learned during my clinical education. One of the greatest opportunities as family physicians is the trust relationship that develops over time with patients, thus allowing physicians to educate, advise and advocate for their patients. Listening to the patient’s perspective is of paramount significance to this doctor-patient relationship. Furthermore, I have seen the success of collaborating with patients to empower them in their wellness and disease self-management by providing easy-to-understand patient handouts and evidence-based resources, particularly on nutrition, active lifestyle, and mental health. Motivational interviewing is an important skill that I will continually develop throughout my career. Also, lifelong learning is essential to stay current with available scientific research and discovery. Moreover, efficient use of electronic medical records (EMR) can streamline information gathering and communication, including tracking trends, pre-visit planning, coordination of tasks amongst the diverse health care team, online patient portals with e-mail capability between provider and patient, and after-visit summary for the patient to take home. Finally, I plan to incorporate osteopathic manipulative treatment (OMT), where appropriate, into my future practice as an additional tool that I can offer patients, especially those who prefer non- pharmacological or non-invasive therapy.

Medicine is one of the rare professions that allows us to use our mind, body and soul to make a positive impact on people’s lives. It is a true privilege to serve others. As such, I am working hard to build a strong foundation in order to achieve the Triple Aim by becoming a competent, compassionate and humanistic doctor who continually reflects on my role as a caregiver in an interdisciplinary team.


1 Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. May 2016;353:i2139.
2 Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008;27(3):759-769.
3 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
4 Simpkin AL, Schwartzstein RM. Tolerating Uncertainty –The Next Medical Revolution? N Engl J Med. 2016; 375(18):1713-1715.
5 Shared Medical Appointments/Group Visits. American Academy of Family Physicians website. http://www.aafp.org/about/policies/all/shared-medical.html. Accessed October 15, 2016.
6 Transforming the organization and delivery of primary care. Agency for Healthcare Research and Quality website. https://www.pcmh.ahrq.gov/. Accessed October 26, 2016.
7 Daniel H, Sulmasy LS. Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings: An American College of Physicians Position Paper. Ann Intern Med. 2015;163(10):787-789.