How the performance art paradigm relates to population health
If you’ve ever attended a performance of the Blue Man Group, you almost certainly remember the quirky mix of drumming, comedy, food fights and audience interaction, all performed wordlessly and in deadpan, anonymous blueface.
If you are a performance art aficionado, you may have thought about the themes, the techniques and the process of the performance. Alternatively, you may also think about the show’s applicability to other life issues, for example, healthcare.
Specifically, what we can learn from the men in blue about patient-centered population health management?
There are four relevant characteristics of a performance like that of the Blue Man Group that we can also apply to population health initiatives: standardization, localization, personalization and continuous adaptation.
Standardization. The show depends on perfect choreography and split-second timing, all designed to appear entirely impromptu. Apart from some localization and personalization, each show is virtually identical. That consistency is essential to the outcome: a delighted audience.
Localization. The venue is woven into the performance, and each venue is unique. So while the overall scripting and choreography are the same in each venue, the specifics are adapted to local conditions. Taking advantage of what is available and unique in each setting is part of what makes the shows work so well.
Personalization and improvisation. Interaction with the audience is an essential element of the performance. Thus, there is a personalized, improvisational element to the show, but one that is tightly controlled to ensure just the right kinds of reactions.
Adaptation. While not evident to any given audience, the show is a continuous work in progress, enhancing what works, adjusting what doesn’t and adding new material to keep things fresh.
So how might one apply all of this to healthcare? Well first of all, let’s define the term “patient-centered population health management.” Think of it as improving the overall health status of a population—whether a locality, a member base, a patient panel or a disease community—by optimizing the care of the individuals comprising that population, all in the context of a learning health system.
Care for individuals results in a body of data from which we can measure the quality, outcome and process of care relative to best practice. This data also enables us to apply predictive models to identify those population members who would most benefit from additional attention. This, in turn, gives us the information to inform all care team members—both formal and informal—about relevant best practices, and to deliver truly personalized coordinated care in partnership with patients and their families. All of this further expands not only comprehensive, longitudinal records for individuals, but also combines to produce a body of evidence to enhance our knowledge of best practices and what should be measured.
This all relates back to the importance of standardization, localization, personalization and adaptation in this system. Many of the quality and cost issues in healthcare today can be traced back to unwarranted variability, poor communication, and lack of coordination. The Dartmouth Atlas of Healthcare (US) and the NHS Atlas of Healthcare (UK) both graphically illustrate the extent of variability in the delivery of care. Too often individual care team members are each trying to deliver a stellar solo performance on a crowded stage. Just as tight choreography is essential to a flawless stage performance, an evidence-based, multidisciplinary shared care plan is essential to optimizing both the outcomes and costs of care for individuals with complex, chronic conditions.
In a performance, we know from the positive reactions of the audience that the performers have achieved that perfectly standardized choreography. In healthcare, we know it from measurement: process measures, quality measures, outcome measures, cost and utilization measures, and patient satisfaction measures.
And then there is localization. All healthcare is essentially local and reflects available services, payment models, cultural norms and the regulatory environment. It may be delivered nearby, yet directed by a care manager in a far-away center of excellence. Services may be outsourced beyond national borders and delivered virtually. Care may leverage the sophisticated services of an academic medical center or those of a dedicated rural community outreach worker. But to achieve consistent, high-quality outcomes, that localization still needs to follow the script of best practice. Care plans must take local conditions into account. All members of the care team must have appropriate access to comprehensive, shared, longitudinal, health and care records.
Healthcare is always about people, which is where personalized improvisation comes in. While high-tech, precision medicine using genomics and customized drug compounds is what gathers all the press, personalization is actually a continuum. It encompasses adjusting standard medications to find a therapeutic regimen that will work with a patient’s life and finances. It means listening to patient goals and preferences and building them into the care plan. It’s about providing educational materials in the correct languages. It is understanding the relationships between providers and knowing who does what task on the care team. And it’s supporting shared decision making with full access to shared health records.
Finally, there is the learning health system. Like the Blue Man Group performance, improving healthcare should be a continuous work in progress. This is where the health histories of an entire population foster understanding of what is effective, and what is not. It is where researchers combine lab studies with the results of actual practice; where a health system can select the lowest cost option from a number of equally effective treatments; where a health plan can see which approaches to patient engagement reduced unnecessary hospitalizations; and where patients can select providers on the basis of results.
Where does this play out in practice? Here are three examples:
- In Rhode Island, a state-wide commitment to shared longitudinal health and care records has made it possible to reduce unnecessary readmissions by as much as 18 percent. There, clinical event notifications tell primary care providers when their patients are being discharged from the hospital, supporting an evidence-based transition of care model.
- In Chile, a pilot program spanning healthcare regions has created comprehensive virtual care records to support the automatic identification of patients at risk for chronic conditions such as diabetes or high blood pressure. This makes it possible to employ best practice interventions—that is, standardization—within the context of the unique local Chilean healthcare system.
- In London, a clinical service of the Royal Marsden Cancer Hospital is supporting evidence-based international best practice for patients with serious illnesses through shared care plans. The system takes into account the governance and care delivery structure of the local English NHS. Comprehensive patient and provider identity management and consent-based information sharing ensure that only legitimate care relationships are supported. The shared care plan is accessible to patients and their families as active members of the care team. Finally, continuous data gathering supports further research into how best to deliver personalized, urgent and end-of-life care to seriously ill citizens.
No single organization or information system has yet raised coordinated care to an art form. Still, a patient-centered approach to population health management, within the context of a learning health system should ultimately result in the kind of performance that makes everyone happy.