Medical Homes’ Role in Advancing Integrated Patient Care and How Clinical Labs Add Value James M. Crawford, M.D., Ph.D. Department of Pathology and Laboratory Medicine North Shore-Long Island Jewish Health System Hofstra North Shore-LIJ School of Medicine • • • • • • • • • • • • • • • • • • Pathology: Brief History 1850 – 1920 Birth of modern Pathology/Laboratory Medicine Vast enhancement of Population Health 1920 – 1950 Birth of modern Medical Practice Establishment of effective therapies 1948 – 2000 Age of the National Institutes of Health Spectacular advances by Investigative Pathology 2000 – 2010 Pivot into “Translational Research” Evidence of effective outcomes? Development of “Personalized Medicine”? 2010 – 2020 Leadership in Patient-Centered Care? Leadership in Population Health? Leadership in Learning Health Systems? Leadership in Value-Based Physician Networks?
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Pathology: Brief History - Executive War College · 2017-04-02 · Integrated clinical data from all care sites* Integrated ancillary data (e.g., all laboratory tests, all referrals)*
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Medical Homes’ Role in AdvancingIntegrated Patient Care and How Clinical Labs Add Value
James M. Crawford, M.D., Ph.D.Department of Pathology and Laboratory Medicine
North Shore-Long Island Jewish Health SystemHofstra North Shore-LIJ School of Medicine
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Pathology: Brief History1850 – 1920 Birth of modern Pathology/Laboratory Medicine
Vast enhancement of Population Health1920 – 1950 Birth of modern Medical Practice
Establishment of effective therapies 1948 – 2000 Age of the National Institutes of Health
Spectacular advances by Investigative Pathology2000 – 2010 Pivot into “Translational Research”
Evidence of effective outcomes?Development of “Personalized Medicine”?
2010 – 2020 Leadership in Patient-Centered Care?Leadership in Population Health?Leadership in Learning Health Systems?Leadership in Value-Based Physician Networks?
For each generation:
It is our “watch”.
The forces in motion now will determine the trajectory of our specialty for generations of Pathologists that follow us.
The Challenge
How does Pathology turn the corneron “Primary Care”, “Access” and “Population Health”?
Personalized Medicine
Patient Centered Medical Home
Population-based Healthcare Outcomes
ACCE
SS
MEDICAL SCIENCE
HIT
The National Environment
3/2009: American Recovery and Reinvestment Act
3/2010: Patient Protection and Affordable Care Act
HITEC
ACO
2009 2010 2011 2012….
Electronic Health Records
Physician Network Consolidation
American Recovery and Reinvestment Act 2009
Page 354:
(C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS.—(i) IN GENERAL.—No incentive payment may be made under this paragraph in the case of a hospital-
based eligible professional.(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘hospital-
based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.
Enter the concepts of:“Patient Centered Medical Home”
“Advanced Medical Home”“Patient Centered Medical Neighborhood”
“Patient Centered Medical Home” Primary Care Practice
“Advanced Medical Home” Specialists delivering“primary” care
“Patient Centered Medical Neighborhood” Continuity of care throughall delivery sites
PCMH: DefinitionAn approach to providing comprehensive primary care through a healthcare setting thatfacilitates partnerships between individual patients, their personal physicians, and, when appropriate, the patient’s family.
• Each patient has a personal physician• This personal physician directs the primary medical care received by the patient• The personal physician takes responsibility for arranging care for all of the patient’s
health needs• The personal physician coordinates the patient’s care across all elements of the
complex health system
Patient Centered Medical HomeOPERATIONAL PRINCIPLES*• Healthcare quality and safety are integral objectives of a PCMH• Patients should have enhanced access to healthcare through the PCMH• Payment for healthcare services should recognize the added value
provided to patients who have a patient-centered medical home
EXPECTATIONS• Excessive utilization of healthcare services will be reduced• The “patient experience” will improve• Primary Care Providers will have more time to spend with their patients• The healthcare outcomes of the population will improve
*2007: AAP, ACP, AAFP, AOA
PCMH: Brief History1967 American Academy of Pediatrics (AAP): concept of a chronic care “home”2001 Institute of Medicine (IOM) report: Crossing the Quality Chasm: A New Health
System for the 21st Century2005 Institute of Medicine (IOM) report: Building a Better Delivery System: A New
Engineering/Health Care Partnership2004 American Academy of Family Physicians (AAFP): endorses PCMH2006 American College of Physicians (ACP): endorses PCMH
American Osteopathic Association (AOA): endorses PCMH
2006 Patient Centered Primary Care Collaborative (PCPCC) established2007 Joint Principles for PCMH articulated by AAP, AAFP, ACP, AOA
National Committee for Quality Assurance (NCQA; founded 1990) incorporatesJoint Principles into their “Physician Practice Connections” (PPC) guidelines
2008 NCQA begins deeming physician practices for meeting PPC-PCMH standards2009 American Recovery and Reinvestment Act (ARRA): $30B of adoption incentives for
“meaningful use” of certified Electronic Health Records (EHR) : MedicareInitiation of numerous Medicare demonstration programs
2010 Patient Protection and Affordable Care Act: Patient-Centered Demonstrations
PCMH Activities
• Enhanced Access• Team approach• Registries (pop. mgmt)• Active care coordination• Quality and safety systems• Advanced patient engagement• Information systems foundation
The PCMH “requires a new “mental model” of how primary care delivers value”
David Nace, 2010
Direct Patient Care
Care Coordination
Patient Education
Prevention
0
2
4
6
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10
12
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Physician (Based on a panel size of 2500 patients)
Hou
rs /
Day
7.4 hours/day
2 hours/day
2 hours/day
7 hours/day
8 Hour Day
Practice improvements often fail because they rely on the willingness of physicians, who are already too busy, to take on additional work.
- Tom Bodenheimer
Taking care of patientsHours required for full portfolio of care
Direct PatientCare
Optional
David Nace, 2010
Patient Centered Medical HomeBuilding a team model
16
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4
2
Patient Flow Manager
Physician Care Manager
Midlevel Pharmacist IT
Hou
rs/D
ay
David Nace, 2010
Patient Centered Medical HomeKey Components of a Transformed Practice
Comprehensive Care
Patient Engagement
Enhanced Access Coordinated Care
Team of Providers EHR with Registry Function
Additional non-physician providers support medical home’s ability to provide additional services
Provides data around key patientmetrics to help track and monitorpatients allowing for improved overall patient management
David Nace, 2010
The value proposition for the PCMH*
INTEGRATED DELIVERY SYSTEMS (for example)
• Group Health Cooperative of Puget Sound: 0.2% PMPM decrease for PCMH patients;16% decrease in hospital admissions.
• Geisiger Health System PCMH model: 7% PMPM decrease for PCMH patients;18% decrease in hospital admissions.
• VA Midwest Healthcare Network (VISN 23): 27% decrease in hospital admissions/Emergency Department visits
• HealthPartners Medical Group/BestCare PCMH Model: 8% decrease in overall costs 24% decrease in hospital admissions; 24% decrease in Emergency Department visits
• Intermountain Healthcare Medical Group Care Management Plus PCMH Model:25% decrease in hospital admissions for diabetics; $53 PMPM reduction
What is the role of Pathology in “Patient Centered” Healthcare?
Patient Centered Medical HomeKey Components of a Transformed Practice
Comprehensive Care
Patient Engagement
Enhanced Access Coordinated Care
Team of Providers EHR with Registry Function
Additional non-physician providers support medical home’s ability to provide additional services
Provides data around key patientmetrics to help track and monitorpatients allowing for improved overall patient management
David Nace, 2010
Patient Centered Medical HomeKey Components of a Transformed Practice
Comprehensive Care
Patient Engagement
Enhanced Access Coordinated Care
Team of Providers EHR with Registry Function
Additional non-physician providers support medical home’s ability to provide additional services
Provides data around key patientmetrics to help track and monitorpatients allowing for improved overall patient management
David Nace, 2010
Sinard & Morrow, Human Pathol 2001; 32: 143-148
Patient
Specialists
Rehabilitation Acute Care
Home Care
Imaging
Labs
Insurance
Employer
Community
Patient Centered Health Care
ca. 2010
Patient
Specialists
Rehabilitation Acute Care
Home Care
Imaging
Labs
Insurance
Employer
Community
Patient Centered Health Care
ca. 2010
frustrationfrustration
The position of the Office of the National Coordinator*
• It is the local multistakeholder alliances that will effect change.• Information is the lifeblood of medicine.• ‘Meaningful use’ is the key to unlocking the potential of Health IT
for Primary Care, Specialty Care, and Hospitals, because it focuses not on the technology but on its use.
• Five domains of focus:- Quality, Safety, Efficacy, Access- Public and Population Health- Engagement of Patients and Families- Coordination of Care- Privacy and Security
• These domains accord perfectly with the PCMH.*David Blumenthal, 3/30/2010
Information Management Requirements†
Patient Access and Communication appointment schedulingclinical information/PHR*education informationself-management support
Patient Tracking and Registry organizing clinical data*managing disease conditions*
Care Management guidelines, Decision Support*electronic prescribingtest tracking*tracking referralstracking Continuum-of-Care*
†National Committee for Quality Assurance 2008
Patient Centered Medical Home
*Pathology: primary dataor potential coordinator
Performance Reporting and Improvement
Measures of physician and practice performance*Measures of healthcare outcomes
Safety and Quality of healthcare*Specific disease management outcomes*
Patient experience and satisfaction (Note: role of Phlebotomy services)
Ed note: These tools help the physician practice achieve improved outcomes;they are not construed as a “policing” function
National Committee for Quality Assurance 2008
Patient Centered Medical Home
*Pathology: primary dataor potential coordinator
Patient Management
Previsit planning (Laboratory testing*, Radiology testing, Dietary restriction)Patients needing clinical review or action*Monitoring patients on specific medicationsPatients needing reminders for preventive care, specific tests, follow-up*Patients who might benefit from care management support*
Patient Centered Medical Home
*Pathology: primary dataor potential coordinator
Population Management
Integrated clinical data from all care sites*Integrated ancillary data (e.g., all laboratory tests, all referrals)*Healthcare Resource utilization
Physician office visits, use of ancillaries, need for acute care*Real-time tracking of Claims data*
to include use of Pharmaceuticals*Real-time tracking of Safety and Quality Outcomes*Real-time tracking of the Patient Experience*Disease Management Outcomes*Biometrics (e.g., weight, body-mass index, blood pressure)*Laboratory values as primary data on patient status (e.g., HbA1c, lipids)*Data on Lifestyle management (e.g., activities, dietary education)*
Physician Practice outcomes*Testing of Evidence-Based Medicine within your healthcare organization*Testing and validation of Safety and Quality initiatives*Identification of Adverse Events*Patient Compliance*Efficacy of Lifestyle, Wellness, and Disease Management programs*Access to Preventive Screening programs*Delivery of healthcare at lowest cost service location*Return-on-investment of HIT solutions and the PCMH*Data on Lifestyle management (e.g., activities, dietary education)*
Patient Centered Medical Home
*Pathology: primary dataor potential coordinator
There is no current payment model for these “pathology” activities- ? Consultation for appropriate test utilization ?*- ? Access to “pathology-specific” demonstration projects ?*
We are excluded by federal law from receiving “practice” payments.
Attribution – and Distribution – of “shared savings” is yet to come.
When (not “if”) ‘Bundled Payments’ arrive, the allocation of funding will be a local event.
Where will Pathology/Lab Medicine be if not already recognizedlocally for our value proposition in patient management?
Payment issues
*College of American Pathologists: current advocacy
You can’t retrofit Laboratory into the Medical Home/ACO model.You have to be part of the design in order to pre-establish your value.
What-if
Master Patient Registry
Laboratory Information System
In-Patient EHR Ambulatory EHR
Registration and Billing
RHIOPatient Experience
Patient Outcomes
The Learning Healthcare System
(1) EHR Database Biostatistics (2) Research Output
(3) Occupational Health (4) Genomics
♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦
Physicians
Patient EHR Record
(5) NationalBenchmarking(2.1) Laboratory Data
Claims
NSLIJ “Current” Physician Network
Hospitals
Ambulatory Care Network
Acu
ity
$
$
$
MG PCP* Affiliated
Inpatient Revenue = 64%
Outpatient Revenue = 36%
2010
Market Share = 26%
MG Specialties
*MG PCP: Medical Group Primary Care Providers
Market Share = <10%
NSLIJ “Value-Based” Physician Network
Hospitals
Ambulatory Care Network
$
$
AffiliatedMG PCP
Market Share
?
?
MG Specialties
Pathology: supporting Physician Offices; sourcing data for network
Department of Pathology and Laboratory Medicine
NSLIJ HS:Ambulatory EHR
Ambulatory Care Network
NSLIJ Laboratories:uniform Laboratory Information SystemIntegration of service unitsIntegrated business/leadership model
NSLIJ HSPhysician Practices
Patient-CenteredQuality Outcomes
Population-basedImproved Healthcare
OutreachPhysician Practices
Penetration of market
ATLAS, OtherAllScripts
Convergent Objectives: 2010-2012
Find the “strongest signal” in yourlocal healthcare environment
Work with those stakeholders.Make your own business future.
The Role of Pathology/Lab Med• Primary informant on “absolute” measures of health status.• Colleague to physicians across the continuum-of-care:
- Mastery of disease pathobiology- Medical Director of all clinical diagnostics
to include: advanced diagnostics of “Personalized Medicine”- first Providers to “see” the data readouts- Responsible for the largest single source of medical data- Expert on data analytics, population outcomes
• System expert in effective delivery of healthcare resources.• Get involved locally: Health System
Ambulatory Care NetworkPrimary Care Physician PracticesCivic agencies, local employers
The Message• Pathologists should actively seek participation in demonstration
pilots: PCMH, Coordinated Care, EHR (and PHR) deployment.• Pathologists should be drivers of EHR (and PHR) data flow. • Pathologists, as integral members of the Coordinated Care
Team, should be experts on test selection and interpretation for individual patients.
• Pathologists should inform regional practices on test utilization across populations, to ensure safety, efficacy, and utility.
Expert, Teacher, Scholar, Advocate
Most importantly:Pathologists/Laboratory Directors are leaders first, and utilize their extraordinary professional skills to promote improved healthcareoutcomes across the populations they serve.
Corollary:Pathologists/Directors have to step forward as leaders withintheir regional health systems (however integrated or fragmentedsuch systems may be).
ErgoPathologists and the Clinical Laboratory have a central role to play in the Patient Centered Medical Home, the Medical Neighborhood, and the Accountable Care Organization models