Transcript P4 gold with circles

Medical Homes and “Learning Health
Care Systems”:
Engines of Success for Turbulent Times
for Primary Care and U.S. Health Care
4th Annual Primary Care Summit
Rocky Hill, Connecticut
November 3, 2011 | Eric B. Larson, MD, MPH
Vice President for Research, Group Health
Executive Director, Group Health Research Institute
Lecture Outline
Where have we been, where are we going?
• IOM defined our challenges with To Err is Human (2000) and Crossing the
Quality Chasm (2001) as problems in quality, safety, cost & value.
• By 2004, we hoped the “chaos” could “spur innovation”
• 2010: U.S. health reform law is passed and implementation begins
• 2011: Facing daunting challenges for primary care and health care in general
The promise of “learning health care systems”
• Patient-centered medical home and lessons learned to-date
• Opportunities for primary care to lead based on patient-centered medical
home
• Other examples
Innovation is not enough!
U.S. Health Care: 2000-2001
The industry was both shaken and inspired by two powerful
Institute of Medicine reports describing crises in quality, access,
value, affordability, and safety.
To Err is Human:
Building a Safer Health System
IOM reported:
• As many as 98,000 people die in hospitals each year due to preventable errors.
• Errors result in total annual cost of $17 billion to $29 billion.
Recommended strategies:
• Establish national focus to enhance safety knowledge base
• Develop national reporting system
• Raise standards and expectations
• Implement safety system to ensure safe practices
Crossing the Quality Chasm: A New
Health System for the 21st Century
Concluded that U.S. health care:
• Is poorly organized, overly complex
• Is inefficient and wasteful
• Operates in silos
• Is especially problematic for those with chronic illness
• Requires fundamental sweeping redesign of the entire system
Recommended ways to improve safety, effectiveness, patient-centeredness,
timeliness, efficiency, and equity.
Crossing the Quality Chasm: A New
Health System for the 21st Century
10 rules to redesign care:
1. Continuous healing relationships
2. Customization based on patient needs and values
3. Patient as a source of control
4. Shared knowledge and free flow of information
5. Evidence-based decision making
6. Safety as a systems property
7. Transparency
8. Anticipation of needs
9. Continuous decrease in waste
10. Cooperation among clinicians
Change was Certainly Overdue
•
Medicine is locked in a craft model rooted in 18th century
•
20th Century brought wonderful technical capacity and innovation
•
Now, great complexity, fragmentation, and ability to harm
•
Can we shift to "patient-centered care"?
•
Ideally based on ongoing doctor-patient relationships
--Merry MD, Quality Progress 2003; 31-5
2004: GIM Task Force Examines “Chaos”
in American Health Care
“Every day, patients, their doctors, and other caregivers team
up to achieve unprecedented health improvements….
Prospects for medical science, informatics, and service
delivery have never seemed brighter. Yet inefficiency, unsafe
systems, medical errors and a quality chasm between the best
possible care and routine everyday care plague the delivery
non-system of U.S. health care.”
-- “System Chaos Should Spur Innovation” a report from the Task Force on
the Domain of General Internal Medicine (Annals of Internal Medicine, April
19, 2004)
2004: GIM Task Force Examines
“Chaos” in American Health Care
Cost of care is rising rapidly with no evidence that this will lead to
better outcomes.
Emergency departments and hospitals are overcrowded, often
because medical care is underdeveloped and inaccessible.
People with sufficient wealth see “boutique” practitioners offering
guaranteed access to care that most insured persons once considered
routine.
Meanwhile:
• More than 40 million Americans are uninsured.
• Declining reimbursements discourage physicians from accepting new
Medicare patients.”
Personal Anecdote from 2004
A fellow and new faculty member: “My 85-year-old grandmother just fell and
broke her hip. I need to fly to Boston to make sure something doesn't go
wrong."
EBL: "That's really good of you, a wonderful thing to do. … (long pause)
But, think of what you just said."
What does this exchange say about:
• Our trust in our own profession?
• The reliability of our nation’s health care system?
U.S. Health Care: 2000-2001
The industry was both shaken and inspired by two powerful
Institute of Medicine reports describing crises in quality, access,
value, affordability, and safety.
Fast Forward to 2011
Now we know that simply believing that “system chaos should
spur innovation” was insufficient – particularly in light of:
• market forces that drive people out of primary care
• persistent uninsurance and
• inadequate access to services
In Fact, the Chasm has Grown Wider
The Commonwealth Fund recently reported:
•
U.S. ranks last out of 19 countries on measures of
“mortality amenable to health care.”
•
This is down from 15th in past five years as other nations
raised the bar on performance.
•
Up to 101,000 deaths could be prevented each year if U.S.
raised standards of care to benchmark levels abroad.
•
U.S. spends two times what other nations spend on health,
but there’s overwhelming evidence of inappropriate care,
missed opportunities, and waste.
Many Big Challenges Ahead
An aging population
Increases in obesity, diabetes, and other chronic illness
Rising cost of drugs, medical equipment, and care
A market-driven health care economy
• encourages more care rather than better care
• prices not linked to value
• perverse incentives
• paying more for care here than abroad
Many Big Challenges Ahead
The new health reform law extends access and coverage to
millions.
But we need more specific solutions for controlling costs,
improving quality.
One Proposal: The Creation and Support of
“Learning Health Care Systems”
The term comes from IOM’s 2009 Roundtable on Evidence-Based
Medicine, where participants identified best practices for generating
and applying evidence in health care.
Problem: Evidence is not available when needed to guide clinical
decision-making
Problem: Evidence is not applied for effectiveness and efficiency
Opportunity: To build knowledge development and application in to
health care delivery so we can:
• improve today’s care
• address growing demand for future evidence-based care.
IOM Group’s Recommendations on
“Learning Health Care Systems”
A new clinical research paradigm to draw clinical research closer to
clinical practice
Development of new study methodologies adapted to the practice
environment:
• Scientists and clinicians working together
• Studies occurring in everyday practice settings
Comprehensive deployment of electronic medical records that can be
linked and mined for research.
Stronger notion of clinical data as a public good.
Attributes of a Learning Health Care System
Leverages health information technology (data repositories drawing
from electronic medical records)
Patient-centered and clinical decision support
Patient engagement
Use of evidence-based clinical guidelines
Research and clinical care integrated through scientifically rigorous
cycles of PDCA (Plan, Do, Check, Adjust)
IOM Group’s Recommendations on
“Learning Health Care Systems”
With these changes we can have a learning health care system where
researchers:
• help design and implement innovations in practice
• draw data from demonstrations and analyze it
• provide data to clinicians, who use it for further improvement and
innovation
Knowledge flows bi-directionally
Research influences practice; practice influences research
The Learning Health Care System
Bi-directional, reciprocal learning can address priorities for the nation and its
health care systems.
The Learning Health Care System
Research on the Patient-centered Medical Home
in a Learning Health Care System: Group Health
2002 “Access Initiative” came first
• Group Health has always been primary-care based; aspired to be
patient-centered.
Reputation and past performance in “managed care” and as a traditional
HMO: Access was a problem.
• Access Initiative elements included:
Same-day appointments
Open access to specialists
A new EMR with secure website for members
Ambitious productivity standards
Reimbursement change
Research on the Patient-centered Medical home in a
Learning Health Care System: Group Health
UW/GH study of “Access Initiative” showed:
• Increased patient satisfaction
• Markedly improved access and productivity
• But no gains in clinical quality, and
• A dramatic negative impact on primary care provider work life
Next step:
• Patient-centered medical home pilot
• Can it improve quality and revitalize primary care?
• Our design benefitted from “lessons learned” through the “Access
Initiative”
Patient-centered Medical Home to
Revitalize Primary Care
Reinvigorated core attributes of primary care
System support for chronic illness care
Advanced information technologies (EMR, registries, reminders, patient
portals)
Supportive physician payment methods (promotes medical home goals,
not simply volume)
Design principles for Group Health’s pilot:
• Panel size reduced from 2,300 to 1,800 patients
• Appointment times increased from 20 to 30 minutes.
• Expanded multi-disciplinary clinical teams
• Desktop time
• E-technology and communication (EMR and secure email with patients)
Medical Home Change Components
PCMH Model
Point-of-care changes
• Calls redirected to care teams
• Secure e-mail
• Phone encounters
• Pre-visit chart review
• Collaborative care plans
• EHR best practice alerts
• EHR prevention reminders
• Defined team roles
Patient-centered outreach
• ED & urgent care visits
• Hospital discharges
• Quality deficiency reports
• e-health risk assessment
• Birthday reminder letters
• Medication management
• New patients
Management & payment
• Team huddles
• Visual display systems
• PDCA improvement cycles
• Salary only MD compensation
Reid RJ et al, Health Affairs 2010;29(5):835-43
Larson EB et al, JAMA 2010; 306(16):1644-45
Reid RJ et al, Am J Manag Care 2009;15(9):e71-87
Patient Experience at Group Health’s
Medical Home
Significantly higher scores for patients at
Medical Home pilot clinic
Year
1
Year
2
Quality of patient-doctor interactions
Shared decision making
Coordination of care
Access
Helpfulness of office staff
Patient activation/involvement
Goal setting/tailoring
Compared to
controls:
Medical Home
higher
Medical Home
lower
Difference not
significant
Staff Burnout at GH Medical Home
Marked improvement in burnout levels at prototype clinic at 1 year
Control Clinics
Medical Home
Emotional Exhaustion
Baseline
54.2%
44.4%
12 month
19.4%
54.5%
**
Depersonalization
Baseline
25.0%
25.0%
12 month
30.4%
18.8%
Lack of Personal Accomplishment
Baseline
12 month
-60%
18.2%
25.0%
25.6%
10.0%
-40%
-20%
0%
20%
40%
% Patient Care Employees rating as "Moderate/High"
60%
Utilization and Costs in Group Health’s
Medical Home
Year 1:
• 29% fewer ER visits
• 11% fewer preventable hospitalizations
• 6% fewer but longer in-person visits
• No significant difference in total costs between Medical Home and
control clinics
Year 2:
• Significant utilization changes persisted
• Overall patient care costs lower at Medical Home (~$10 PMPM)
Lessons Learned from Group Health’s
Patient-centered Medical Home Pilot
Patient-centered care saves costs by lowering inappropriate use of
emergency care and avoiding preventable hospitalizations.
Investment in a medical home can achieve relatively rapid returns
across a range of key outcomes, even in an already integrated
system
The Group Health PCMH evaluation provides some of the first
empirical evidence of the benefits of the medical home.
The evaluation has led Group Health to spread the PCMH to all 26
of its medical centers.
Patient-Centered Medical Home:
2011 and Beyond
Medical Home principles are just basic primary care principles.
But the Medical Home principles address:
• Complexity of today's patients (especially chronic disease and
geriatrics)
• Complexity of fragmented, highly specialized system we work in
• Use of technology in ways that are patient centered
Payment is changed.
• Experts agree: Payment reform is necessary for MH to endure.
Medical Home is prominent in the U.S. health reform law: Key will be
spread and local execution.
More Examples of Innovation in Group
Health’s Learning Health Care System
A shared-decision making initiative:
• Informed choices may reduce unwarranted variations in treatment
for preference-sensitive medical conditions
• Current study is examining use of DVDs, booklets, Web-based
videos to help patients make informed choices
More Examples of Innovation in Group
Health’s Learning Health Care System
Shared-decision making evaluation focuses on 12 kinds of surgery, including:
• Knee replacement
• Hip replacement
• Cardiac procedures
• Low back surgery
• Hysterectomy
• Prostate surgery
• Breast cancer (mastectomy vs. lumpectomy)
Researchers will learn how the initiative affects:
• Use of surgery
• Total health care utilization
• Total costs
More examples of innovation in GH’s
Health’s learning health care system
Value-based benefit design
• Pilot of Group Health’s 9,000 employees
• Higher co-pays for high-cost, low-value services, such as high-tech
radiology
• Wellness incentives
• AHRQ-funded study to evaluate impact on employee health, quality of
life, productivity, utilization, costs
Pediatric oral health

Research on the integration of oral health promotion practices into wellchild care showed high satisfaction among patients and physicians.

Resulted in dissemination at all 26 Group Health clinics.
Example of Prevention in a Learning
Health Care System: Free & Clear
• 1985: Group Health launches study of Free & Clear, a groundbreaking, phonebased smoking cessation program funded by NCI.
• 1991: Research shows Free & Clear boost quit rates 50%
• 1998: Study of 90,000 Group Health members shows providing coverage for
smoking cessation increases quit rates.
• 2002: Study of blue-collar workers demonstrates a 27.5% quit rate and 27% ROI
due to reduced utilization for tobacco-related illness.
• 2002: Boeing offers Free & Clear at no cost for its 150,000 employees; 10%
participation; quit rates of up to 35%.
Example of Prevention in a Learning
Health Care System: Free & Clear
• 2003: Free & Clear, Inc., becomes an independent business with investment from
venture capitalists.
• 2009: Washington State announces state smoking rate hits a new low for the 6th
consecutive year, thanks in part to Free & Clear.
• Today, Free & Clear, Inc., is the only commercial smoking cessation program
w/proof of effectiveness (>20 clinical trials, 50 program evaluations, >80 peer
reviewed publications).
• Serves >18 state governments and 280 commercial clients (51 in the Fortune
500).
• More than 2 million people have used Free & Clear
Prospects that primary care, revitalized by the Patient-centered
Medical Home can help Achieve Goals of Healthcare Reform:
Access for All at an Affordable Cost
International comparison data support primary care based systems yield
highest quality, best value.
PCMH creates environment where care can be delivered based on basic
primary care principles.
Effective primary care: Keep care local when possible and linked to ongoing
healing relationships.
Spread of PCMH at GH and nationwide demonstrations show •
in the US "all healthcare is local"
•
effective leadership and team function is critical
•
diverse role functions are characteristic
Primacy of cost containment, a local and worldwide challenge
Learning Through Research and then
Evaluation must Continue
Evaluation of PCMH results will be critical to whether PCMH can truly revitalize primary
care in the US and achieve goals of reform.
Research on the effects of primary care will remain valuable and ideally ongoing.
Interesting Example: Einarsdottir, et al.: Regular Primary Care Plays a Significant Role
in Secondary Prevention of Ischemic Heart Disease in a Western Australia Cohort (JGIM
2011;26:1092-7; Editorial – Ogedegbe and Williams: Primary Care Equals Secondary Prevention in Ischemic
Heart Disease)
In a "trohoc" study of 30,000 (mean age 73) discharged with heart disease and
followed to time of death or IHD rehospitalization:
• Frequency of primary care visits divided into quartiles: there was a dose response from least
to most regular visits for both death and IHD rehospitalization.
• HR for mortality and IHD mortality were: 0.71 and 0.65.
Conclusion: Regular primary visitation offers protection against morbidity and mortality
in older people with established IHD. Mechanism unknown but probably related to better
care associated with continuity.
Innovation is not enough.
We must focus on what happens afterward.
Healthcare reform is not enough.
It will provide more universal access, but we need to focus on
what happens after that.
“This is our moment. This is our time. …Our time to bring new
energy and new ideas to the challenges we face.”
“We’ll restore science to its rightful place, and wield technology’s
wonders to raise health care’s quality and lower its cost.”
"It gradually dawns on you that things work, and there are a lot of
people that want to help it work. …Success is cumulative and
optimism builds on cumulative success."
--William Foege, MD, MPH,
Advisor to the Carter Foundation and the
Bill & Melinda Gates Foundation;
Led the successful campaign to eradicate small pox