“The problem-knowledge coupler principle is simple: Gather a large number of variables (medical history findings, physical exam findings, laboratory data) and use a computer to sort them into all the diagnostic or treatment possibilities for a patient’s unique clinical situation.”

Charles Burger, MD
“The Use of Problem-Knowledge
Couplers in a Primary Care Practice”

In 1968, Dr. Lawrence Weed, a physician researcher, posited that the rapid growth of medical knowledge was creating a demand for new ways of providing information in support of evidence-based medical practice. Following his own passion for a disciplined approach to medical record documentation to optimize the care provided to each individual patient, he developed the problem-knowledge coupler.

Problem-knowledge couplers comprise a sophisticated, evidence-based diagnostic and treatment decision support tool, embedded in technology, to manage condition and disease, reduce life-style risk and provide primary care. Couplers match unique patient information and unique characteristics with an extensive medical database to provide guidance tailored to unique individuals.

Couplers are developed through a collaboration among clinicians, informaticians and librarians. They recognize that functionality must be predicated upon combining unique patient information, gleaned through relevant structured question sets, with the appropriate knowledge found in the world’s peer-reviewed medical literature. Two pilot studies indicate that couplers can meet the gold standards of decision making within both a primary care and a specialty practice.

Issues remain about how to best integrate problem-knowledge couplers into clinical practice and whether large-scale outcomes research will support the findings of pilot studies. However, problem-knowledge couplers represent a promising approach that might portend a new model for healthcare delivery in the next millennium.

Dr. Charles Burger, the medical director of Evergreen Woods Primary Care in Bangor, Maine, has been working with computerized problem-knowledge couplers since 1984. Click here to read his article about their use in a primary-care practice, which appeared in the Spring 2010 (Kaiser) Permanente Journal.

Dr. Weed proposed his problem-knowledge coupler theory in 1968 with his article on “Medical Records That Guide and Teach.” More than 40 years later, the idea seems to be a novelty still, yet people like you, who have incorporated it into practice, have nothing but praise for it. Why is it taking so long for it to catch on?
This is by far the most complicated issue here. Physicians who are concerned that it is not “experiential” enough have probably never even used the tool. However, more and more often, thoughtful physicians are recognizing that the job we are trying to do is cognitively impossible  due to the complexity of the information that we have to deal with, and that they’re unable to keep in mind either generally or specifically all the elements of the cases they’re dealing with.

As with all tools, one must be trained to use it. That takes time and commitment. And as with all learning, one goes from novice to master over a period of time, and that can be a significant barrier.

One must follow the path I outlined in the article—reorganizing your practice around the use of new software—and that is a difficult process. It takes a commitment to certain principles to push through on that.

Finally, I am sure that many physicians are offended by the thought that they need a tool for their brain!

Dr. Weed was the president of PKC (Problem-Knowledge Coupling) Corp. in South Burlington, Vt. Do you think there is any onus attached to the fact that the theory has been commercialized?
It’s sad that Dr. Weed is no longer the president—he was forced out a couple of years ago, and I think this has been a disaster. But I do agree that the commercial product limits success to a certain level. I know it is the commercial aspect that dismays some of the leading names in healthcare  and that many professionals support the idea but are dissuaded from actively moving it forward.

Early on, Dr. Weed tried to interest the Library of Medicine, as well as the NEJM, in taking over the project, but nothing happened. It should be managed as though it were an open-source software company.

Forty-two years of technology have brought us a long way. Do you think early reluctance to buy into the proposition had anything to do with the amount of work it must have required, which must have been staggering, before it was fully computerized?
There has been a considerable evolution of the product, but I am not sure that the lack of technology has had anything to do with the reluctance to embrace the science.  Look how slowly physicians have adapted to the EMR!

Is there any proof that PKC results in better outcomes more often? Have those measurements been made?
There have not been enough good studies to say one way or the other. Does the science enable doctors to be more thorough? Yes! Does the patient get better information? Yes! Do I feel that the reliability of the system improves by using them? Yes! Outcomes are a system function, and no single tool can improve them by itself , any more than the medical record can. The problem is that we do not have a system in medicine that has feedback loops so that we can get wiser over time. Here’s a schematic outline of what that process might look like.     

 In his new book, Thinking, Fast and Slow, Nobel-Prize winner Daniel Kahneman  points out the inherent biases that are built into our decision- making process. These same biases are at work when physicians make patient-care decisions. Couplers provide at least some protection against these biases by forcing us to collect all the relevant information on patient problems up front before considering options. We know, for instance, that on average providers make an initial diagnosis within 30 seconds of talking with a patient. From that time on they look for information that confirms that judgment and ignore that which refutes it (called confirmation bias).

Have there been attempts to integrate this science into medical curricula? If so, where have they succeeded?
Sadly, no, though I am trying very hard to put the program in the hands of medical students.

Where can PKC go from here?
Without tools like these, patients take a risk every time they visit their healthcare provider, and I think it is inevitable that this very important technological development will become as vital a part of healthcare as MRIs and CT scans. In my own practice, we have successfully integrated a sophisticated clinical support system into our busy primary-care practice with no loss of productivity. We have standardized inputs at the front end (itself a quality gain),with the variations occurring in the outputs (options) generated by each unique patient situation. We have minimized the chances that the rare or unusual case will be missed, and we are able to provide detailed, current information for the patient. We have shown that it can be done. The only question is whether the profession is willing to minimize the limitations of the human mind to deal with complex data through the use of new tools, and I think that with good, strong leadership that can be accomplished.

Dr. Weed’s new book, Medicine in Denial, published in March 2011, offers a very clear blueprint for using PKC to build a healthcare system that would serve as a hope for the future rather than what it is now, a looming liability.

The book, by David Farrell, MSW, LNHA, Cathie Brady, MS, and Barbara Frank, MPA, and supported by Picker Institute, is “a must read for nursing home administrators, directors of nursing and others in  leadership positions in long-term care. It offers practical, commonsense, easy-to-implement approaches that will yield immediate positive results. It also serves as a wake-up call to leaders who doubt their impact, and as an affirmation to leaders who struggle daily to do a good job.”

Click on the image of the book to view and/or purchase it online.

The award is a component of a program developed by the Hartford Institute for Geriatric Nursing at the New York University College of Nursing in collaboration with the American Association of Colleges of Nursing with funding from Picker Institute and the Commonwealth Fund.

Click here to read about the award. Read more about the program here.

Dr. Don Berwick, center, received the 2011 Picker Award for Excellence on Dec. 5 during the annual Institute for Healthcare Improvement forum. With him are, from right, IHI Executive Direcctor and COO Jeff Selberg; IHI President and CEO Maureen Bisognano; Picker Institute Executive Director Lucile Hanscom; and Picker Board Chairman J. Mark Waxman, Esq.

ORLANDO, Fla.—The Picker Award for Excellence, which recognizes outstanding achievement in promoting and furthering patient-centered care, was awarded to Dr. Don Berwick on Wednesday, Dec. 7, the last day of the 23rd annual national forum hosted by the Institute for Healthcare Improvement, which Dr. Berwick cofounded in 1989.

The award cited Dr. Berwick for a “lifetime of unwavering commitment to improving the quality of healthcare for all people worldwide,” and “the uncommon courage that has made him a true leader in the field.”

In presenting the award, Picker Institute Executive Director Lucile O. Hanscom described Dr. Berwick as  “a passionate advocate for raising the quality of this country’s healthcare to a new standard of excellence” and as being “in the vanguard of every innovative effort to improve healthcare and the way it is delivered.”

“Ever since the Picker Awards for Excellence were inaugurated in 2003,” said  Hanscom, “we’ve taken great pride and pleasure in recognizing people whose dedication to patient- and family-centered care has made them outstanding exemplars of this vital commitment. Don Berwick is just such a person, and his courageous contributions to the field are a beacon whose light illumines and inspires all who believe that the path to achieving a new standard of excellence in healthcare for every single person in this country is to see always through the eyes of the patient to whom it is provided.”

Dr.  Berwick, MD, MPP, began his career as a pediatrician at Harvard Community Health Plan. In 1983 he became the plan’s first Vice President of Quality-of-Care Measurement, in which capacity he investigated quality-control measures in other industries such as
aeronautics and manufacturing and considered their application in healthcare settings.

In 1987, Dr. Berwick co-founded the National Demonstration Project on Quality Improvement in Health Care, designed to explore opportunities for quality improvement in healthcare. He served as co-principal investigator for the project until 1991. In accord with his work with the project, Dr. Berwick left Harvard Community Health Plan in 1989 and co-founded the Institute for Healthcare Improvement.

In April 2010 Dr. Berwick was named by Pres. Barack Obama as administrator of the federal Centers for Medicare and Medicaid Services. He stepped down from the post in late November 2011.

Dr. Berwick graduated from Harvard College with a BA. He received an MPP from the John F. Kennedy School of Government at Harvard University and an MD from Harvard Medical School. He completed his medical residency at Children’s Hospital, Boston.

Dr. Berwick has received many awards, including the Ernest A. Codman Award in 1999; the Alfred I. DuPont Award for Excellence in Children’s Healthcare, 2001; the American Hospital Association’s “Award of Honor,” 2002; the  Purpose Prize for “enlisting wide-scale cooperation and scientifically proven protocols to help hospitals improve care
and save more than 100,000 lives,” 2007; and the 13th Annual Heinz Award for Public Policy, 2007.

He was named a Fellow of the Royal College of Physicians in London in 2004 and Honorary Knight Commander of the Most Excellent Order of the British Empire in 2005.

Dr. Berwick has published more than  130 articles in professional journals on healthcare policy, decision analysis, technology assessment and healthcare quality management. He is the co-author of several books, including Cholesterol, Children, and Heart Disease: an
Analysis of Alternatives (1980), Curing Health Care (1990) and New Rules: Regulation, Markets and the Quality of American Health Care (1996).

Read Dr. Berwick’s address at the Picker Award event, “The Moral Test,” here.

Creating Home: Advocating for Change in How and Where We Age

“Creating Home: Advocating for Change in How and Where We Age” is a consumer education pilot funded by the Picker Institute. In collaboration with its partners, the Pioneer Network developed this project in response to the growing realization that consumer awareness of and advocacy for culture change are critical to its widespread dissemination. Partners included the American Association of Homes & Services for the Aging, American College of Health Care Administrators, American Health Care Association, American Medical Directors Association, The Coalition of Geriatric Nursing Organizations, and National Consumer Voice for Quality Long-Term Care. Click the image above to view project materials.

Meeting the Leadership Challenge in Long-Term Care: What you do matters

Through funding from The Picker Institute, the project team has developed multi-media resources that build on the book’s content. Each web page on this site contains a short video and a downloadable hand-out. Click HERE to visit the Meeting the Leadership Challenge in Long Term Care website.

The book, by David Farrell, MSW, LNHA, Cathie Brady, MS, and Barbara Frank, MPA, and supported by Picker Institute, is “a must read for nursing home administrators, directors of nursing and others in leadership positions in long-term care. It offers practical, commonsense, easy-to-implement approaches that will yield immediate positive results. It also serves as a wake-up call to leaders who doubt their impact, and as an affirmation to leaders who struggle daily to do a good job.” Click on the image of the book to view and/or purchase it online.

VIVE: Development of Tools to Improve Nursing Home Providers’ Assessment Skills

VIVE: The Video on Interviewing Vulnerable Elders, which was released in July 2010, is a tool to teach care managers how to interview nursing home residents using the MDS (Minimum Data Set) 3.0 implemented by CMS in October 2010. As of the end of September 2011, it had been viewed on the Picker Institute and other websited more than 13,500 times. Click on the image above for more information and to view the video.

Culture Change Nursing Homes as Clinical Training Sites: Recommendations to the Field

The Hartford Institute for Geriatric Nursing, New York University College of Nursing (“Hartford Institute”), in collaboration with the American Association of Colleges of Nursing (AACN) and drawing on the experience of the Pioneer Network, with funding from the Commonwealth Fund and the Picker Institute, has developed Recommendations to the Field consisting of six e-Learning Modules.  These Recommendations, which are being widely disseminated to nursing programs and nursing homes, address how to maximize the use of nursing homes as clinical training sites, with one focus being culture change values and practices. Click on the image above for more information and to view and/or download tools and strategies.

One of the ways Picker Institute supports patient-centered care is by recognizing people in healthcare who have made significant contributions to achieving patient-centered care worldwide. 

Click on the images below to read the conversations.

David Farrell, LSW, LNHA

Jennie Chin Hansen, RN, MS, FAAN, CEO of the American Geriatrics Society

Jennie Chin Hansen, RN, MS, FAAN

This Conversation is with Jennie Chin Hansen, RN, MS, FAAN, the CEO of the American Geriatrics Society and the 2011 winner of the Picker Award for Excellence® in the Advancement of Patient-Centered Care in Long-Term Care Settings.

Jennie Chin Hansen is CEO of the American Geriatrics Society, the nation’s leading membership organization of geriatrics healthcare professionals whose shared mission is to improve the health, independence and quality of life of older people. Prior to this she served for two years as president of AARP. In 2005, Hansen had spent nearly 25 years with On Lok Inc., a nonprofit family of organizations providing integrated, globally financed and comprehensive primary, acute and long-term care community-based services in San Francisco. The On Lok prototype became the Program of All-Inclusive Care to the Elderly (PACE) program, which was signed into federal legislation in 1997 making this Medicare/Medicaid program available in all 50 states.

Karen Schoenaman, Deputy Director, Nursing Homes Division of CMS

Karen Schoeneman, Deputy Director, Nursing Homes Division, CMS

This Conversation is with Karen Schoeneman, the winner of the 2010 Picker Award for Excellence^®in the Advancement of Patient-Centered Care in a Long-Term Care Setting. 

Karen C. Schoeneman, M.P.A., has served as the deputy director of the Centers for Medicare and Medicaid Services Division of Nursing Homes since 1989, with the responsibility for surveying and certifying nursing homes. She manages the division’s clinical team, which administers the long-term care survey process, the interpretive guidelines and the Quality Indicators Survey process implemented in 2008. A  nationally recognized expert in the field of changing the culture of aging, Ms. Schoeneman is the CMS lead for this vital issue, which seeks to transform nursing homes from rule-bound institutions to home-like settings by adopting the principles and practices of patient-centered care to greatly enhances the quality of life for residents. At CMS, Ms. Schoeneman has led or co-led the development of all traditional survey process changes since 1993, including revisions in response to the Clinton Administration’s Nursing Home Initiative. She  represents CMS on the Veterans Administration Culture Change Task Force and the Pioneer Network Small House/ Household Project. A founding member of Pioneer Network and an Eden Associate, she is the winner of the 2010 American College of Health Care Administrators Public Service Award.

Dr. Bill Thomas

Heidi Gil, NHA

Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights these contributions. This Conversation is with Heidi Gil, one of the authors of the Long-Term Care Improvement Guide, published in October 2010 by Picker Institute and Planetree.

Heidi Gil is the director of Continuing Care at Planetree.

Has concern for the physical safety of an aging population hijacked the attention that should be paid to their emotional and spiritual needs? Karen Schoeneman, MPA, the deputy director of the nursing home division of the Centers for Medicare & Medicaid Services, and Heidi Gil, NHA, the director of continuing care at Planetree, discuss what some advocates for the elderly are calling “surplus safety” and whether it can diminish the sense of dignity and community that is so important to the well-being of the elderly.

Last year’s healthcare reform legislation continues to be a hot topic wherever and whenever healthcare professionals gather. Two of the best known and most vocal advocates for the elderly—Jennie Chin Hansen, CEO of the American Geriatrics Society and winner of the 2011 Picker Award for Excellence® in Long-Term Care, and Dr. Bill Thomas, founder of the Eden Alternative® and the Green House Project® and winner of the 2009 Picker Award in long-term care—trade views on what has and has not changed over the past year and what the future holds.

“The problem is the culture of not aging in America.
What we’ve got is an American culture that denies aging,
and denies the worth and value of older people. And we
have 16,000 nursing homes to show for it.”

Two champions in the field of eldercare—Mary Jane Koren, vice president for the Picker–Commonwealth Fund Long-Term Quality Improvement Program at the Commonwealth Fund, and Dr. Bill Thomas, a crusader for the de-institutionalization of nursing homes and a partner with Picker Institute in the Report on Aging in America—discuss long-term care in America and its future.

Under one aspect of the program, Picker Institute awards grants to support research agenda initiatives aimed at improving the quality of life in all LTC settings, with the goal of making  patient-centered care a reality in many more nursing homes throughout the country.

Included in the program is the Picker Award for Excellence® in the Advancement of Patient-Centered Care in a Long-Term Care Setting, as well as a robust presence at long-term care-oriented conferences throughout the country.

Please click on the images below for more information.

Picker Long-Term Care
Research Agenda

Picker Institute awards grants to support research agenda initiatives aimed at improving the quality of life in all LTC settings. Please click on the LTC icon for information about past and present Picker Long-Term Care projects.

Picker Long-Term Care Toolbox

This toolbox contains  tools and strategies to assist you in implementing initiatives to meet  your patient- and family-centered care goals in the long-term care field. They have been initiated by numerous  healthcare professionals throughout the country as they design and develop programs to enhance the care provided to patients.

Long-Term Care Improvement Guide

Funded by a grant from Picker Institute, the Long-Term Care Improvement Guide was developed by Picker and Planetree in 2010 as a compendium of best-practice innovations and approaches for initiating and sustaining a resident-centered, relationship-based culture in long-term care communities. Like its partner, the Patient-Centered Care Improvement Guide, published by Picker and Planetree in 2008, this Guide aims to encourage people and communities to take action now.

 
Picker Awards for Excellence® in the Advancement of
Patient-Centered Care in a Long-Term Care Setting

The identification and promotion of  best practices that lead to the advancement of patient-centered care is an important element in Picker Institute’s mission.  The Institute promotes best practices by recognizing outstanding professionals in the field whose work best exemplifies the Institute’s goals and philosophy. The Picker Awards for Excellence were established in 2003 as an educational component of improving patient-centered care. “Our mission is to make the patient’s experience, whether in a hospital or a doctor’s office, a better one,” Institute founder Harvey Picker said in 2008. “The Picker Awards are intended to honor people and organizations who have contributed significantly to this goal, and to highlight them as role models for others in healthcare.”

Hot Topic Conversations with
Long-Term Care Leaders

One of the ways Picker Institute supports patient-centered care is by talking with people who have established a reputation for excellence in the field. These conversations focus on the vital role of patient-centered care in the long-term care area.

Conversations with Leaders in the
Field of Long-Term Care

Conversations with Leaders in the Field of Patient-Centered Care is a regular feature that highlights people who have made significant contributions to achieving patient-centered care worldwide.

Dr. Bill Thomas, an international authority on geriatric medicine and eldercare and the founder of The Eden Alternative^® and The Green House Project^®, received the first individual Picker Award for Excellence^® in the Advancement of Patient-Centered Care in a Long-Term Care Setting on Aug. 14, 2009, at the 9th annual Pioneer Network Conference in Little Rock, Ark.

Dr. Thomas was cited for “his outstanding achievements in envisioning and implementing a new paradigm for long-term care that focuses on nurturing and sustaining a meaningful life for the aging.”

A 1986 graduate of the Harvard Medical School, Dr. Thomas went on to graduate medical training in the Highland Hospital/University of Rochester Family Medicine Residency. While he planned on a career in emergency medicine, a part-time position as the medical director of a small rural nursing home turned into a full-time and lifelong passion for improving the well-being of older people.

In the early 1990s Dr. Thomas and his wife, Judith Meyers-Thomas, developed the Eden Alternative, which embodied a revolution in the status quo in long-term care and offered a creative way to “change the culture” of nursing homes by bringing life and laughter into the lives of elders. The philosophy also called for fundamental changes in the relationship between staff and management. His book on the initial implementation project,  The Eden Alternative: Nature, Hope, and Nursing Homes, was published by the University of Missouri Press in 1994.

On a tour of  America’s nursing-home buildings, Dr. Thomas noted that they were “aging faster than the people living inside them.” This led him to develop a new approach to long-term care supported at first by the Fan Fox and Leslie R. Samuels Foundation and later by the Robert Wood Johnson Foundation. This model of care is now being replicated nationwide.

Dr. Thomas left full-time medical practice in 2004 and continues to lecture at the SUNY Health Science Center’s Clinical Campus in Binghamton. In 2007 he was appointed Distinguished Fellow and Professor of Aging Studies at the University of Maryland Baltimore County’s Erickson School. A very active proponent of person-centered care, Dr. Thomas continues to travel widely, speaking and consulting with groups that are seeking change.

Click here to see Dr. Thomas’s acceptance speech.

Click here to see Dr. Thomas and Dr. Mary Jane Koren of The Commonwealth Fund discuss aging in America.

Click here to see The Picker Report on Aging with Dr. Bill Thomas