Practice Innovations: Which Ones Will Help? Ralph Gonzales, MD, MSPH Associate Professor of Medicine; Epidemiology & Biostatistics Division of General.

Practice Innovations: Which Ones Will Help?

Ralph Gonzales, MD, MSPHAssociate Professor of Medicine; Epidemiology &

BiostatisticsDivision of General Internal Medicine; Dept of Medicine

Outline

• Problems Plaguing Primary Care• Practice Innovations

– Structure of Care/Delivery System• Open Access• Disease Management; Chronic Care Model

– Processes of Care• E-prescribing• Electronic health records• E-mail management• Internet (portal) management• Point-of-service computerized applications

Primary Care circa 1991

Primary Care circa 2006

Problems Facing Primary Care

• Increased Time Pressure

• Increased “Hassle Factor”

• Declining Income

(Time) Pressure CookerFor a typical panel of patients…

Preventive Health Care• 7.4 hours per day to provide all

recommended preventive services. (Yarnall et al. Am J Pub Health 2003;93:635)

Chronic Disease Management• 10.6 hours per day to provide

recommended chronic care services. (Ostbye et al. Ann Fam Med 2005;3:209)

The Hassle Factor

Sommers LS et al. WJM 2001;174:175-9

• Of 376 total visits, 23% of visits generated > 1 hassles.

• On average, 1 hassle lasting 10 minutes for every 4 to 5 patients seen per day.= 40-50 hassle-minutes per

day

• 46% of hassles interfered with quality of care, the doctor-patient relationship, or both.

Primary Care Physician Incomes Are Decreasing

The Impending Collapse of Primary Care Medicine and Its Implications for the State of

the Nation’s Health Care:

A Report from the American College of Physicians

January 30, 2006

ACP Response (2006)

1. The Certified Advanced Medical Home– Focus on patients with multiple chronic

diseases– Accountable for results

• High quality• Increased efficiency• High patient satisfaction

– Eligible for new models of reimbursement

ACP Response (2006)

2. Revise Medicare FFS payment rates… payments for office visits/management

services; and recognize value of coordination of health care (esp. among patients with multiple chronic diseases)

– ↓ payments for technological and procedural services

– Provide payment for email/telephone care

ACP Response (2006)

3. Congress/CMS should provide sustained and sufficient financial incentives for participation in QI programs

– P4P must be non-punitive, and sufficient to offset cost of measuring/reporting quality.

– P4P should be implemented with reimbursement reforms

4. Replace the sustainable growth rate (SGR) formula…

Assessing Practice InnovationsPhysician Adoption• Will it reduce time/hassle factors?• Will it generate more revenue?• Will it enhance the patient relationship?Patient Adoption• Will it improve timely access to care?• Will it reduce out-of-pocket health care costs?System Adoption• Will it reduce total health care costs?• Will it reduce medical errors/improve quality?• Will it enhance patient satisfaction?

The 21st Century Practice “Innovations”

Open (Same Day) AccessOpen (Same Day) Access Primary Care TeamsPrimary Care Teams

Collaborative Care Model; Patient self-Collaborative Care Model; Patient self-managementmanagement

e-Prescribinge-Prescribing

Electronic Health RecordElectronic Health Record

New Types of Clinical EncountersNew Types of Clinical Encounters Email; Internet; KioskEmail; Internet; Kiosk

Open AccessOpen AccessWhat Is It?What Is It?

Core Principle: If capacity = demand, then patients can use a same day app’t system

Core Need: Time-to-Next Appt; No-Shows

Core Concept:-Patients call for appt on the day they can

come in.-Certain patients (elderly; complex

comorbidities) can still make scheduled appts, but these need to be limited.

Open AccessOpen AccessDoes It Work?Does It Work?

• Demand decreased 10% at KP(Murray M, Fam Pract Manag 2000;7:45-50)

• PROS:– Reduce time-to-next appt.– Reduced over-booking– By monitoring capacity/demand, can predict when new

provider hires are needed.– Increased patient satisfaction

• CONS:– Can take months to reduce the “backlog” of demand…– Need for data systems to track demand/access

Murray and Berwick JAMA 2003;289:1035; Murray et al. JAMA 2003;289:1042.

Alaska Native Medical CenterAlaska Native Medical CenterAfter Open-Access System AdoptedAfter Open-Access System Adopted

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Open AccessOpen AccessWhat Can Go Wrong?What Can Go Wrong?

• Example #1: Inadequate Telephone Access– Clinic in NYC started same day access. Told patients:

we will not make appts for you. You need to call the day you want to come. Few receptionists so impossible for patients to get through by phone. Access went down.

• Example #2: Demand > Capacity– Same day access was started but capacity and demand

weren’t measured and matched. Demand was greater than capacity. Doctors were staying until 10 p.m. seeing people who were given appts the same day.

• Example #3: Lack of Provider Buy-In– Part-time physicians refused to work-down the backlog

of demand

Open Access Lessons/Requirements

-Telephone system must be able to handle large call volumes

-System for measurement of demand and capacity

-Contingency plan (daily) for matching fluctuations in demand and capacity

-Ability to reduce the backlog of demand.-Same day access to medical records

Management of Complex Patients

Disease Management• Company-delivered• Patient-target• Core processes

– Identify, communicate with and monitor high utilization patients

– Increase self-management

• Cost-savings critical

Chronic Care Model• Physician-delivered• Physician/patient target• Core Processes

– Self-management– Delivery system redesign

• Multidisciplinary teams; group visits; case manage

– Clinical information system• Registries; reminders;

performance feedback

Innovations in Process of Care

• Telephone management

• Telemedicine

• e-Prescribing• Electronic Health Record• E-mail management• Internet (portal) management• Point-of-service computerized

applications

e-Prescribing

Retail Pharmacy

Computer or PDA

EHR

PBM“RxHub”

“Sure-Scripts”

Mail-Order

Eligibility; Formulary; Benefits

Drug interactionsSafety monitoringCompliance

e-Prescribing

In 2005, 14% of physicians (most in large group practices) used some kind of eRx

Forces Favoring Implementation• Medical errors movement• Low/No-cost programs (to practices)• Adoption of EHRs• P4P

– Incentives for EHRs and e-prescribing.– Facilitate chronic disease management

• Patient convenience• Medicare drug benefit program

– Standards due 2008

Electronic Health Records

• Benefits– Legibility– Accessibility in time and space– Quality Measurement– Patient Safety/Medical Errors– Billing

• Bottom-Line: It’s going to happen…

Will EHRs Enhance Primary Care Practice?

Pizziferri L et al. J Biomed Inform 2005;38:176-88. (HealthPartners)

*Only 29% believed LMR used equal or less time than paper documentation.

Small Practice Viability?Miller R et al. Health Affairs 2005

-Start-up costs $44,000 per FTE, and maintenance $8500 per FTE-yr.

-Recoup start-up after 2.5 years, largest gains from increased coding levels & reduced personnel costs

-After start-up, $23,000 net benefits per FTE-yr.

Do EHRs Improve Health Care Outcomes?

Setting Condition Process Outcome

EHR vs. no-EHRO’Connor, 2005 HealthPartners Diabetes A1c testing No ∆ A1c control

EHR decision support Sequist, 2005 Partners Diabetes OR=1.3 not measured

CAD OR=1.25 not measured

Tierney, 2003 Regenstrief CAD/CHF No ∆ No ∆ QOL, visits,

cost, satisf.

Feldstein, 2006 Kaiser Warfarin ↓CI drugs not measured

Feldstein, 2006 Kaiser Bone Fx BMD; Rx

EHRs in Primary Care

Primary CareRecord

Hospital

Pharmacy

Insurers

Health Dept

Nursing Home

Hospital

Pharmacy

Insurers

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Nursing Home

Will E-Mail Enhance Primary Care Practice?

-Katz SJ et al. JGIM 2003;18:736-44.

-randomized physicians (and their panels); Ann Arbor, USA-academic medical center (IM/FM) (faculty and residents)-structured email system; routing by nurse; no EHR-2 week intervals pre/post-average 12 emails per week

No ∆ Resource Utilization; Time Burden

E-mail in Norwegian Practices-Bergmo TS et al. Int J Med Inform 2005;74:705-10.

-randomized patients within physician; Norway-ambulatory practices-unstructured messaging system + EHR-measured 1-yr pre/post-46% of patients used email at least once

↓ Decreased Office Visits

Internet Portals• Greater security

– Authentication procedures possible– Track sender and receiver access to information– Information cannot be forwarded electronically

• Greater structure of messaging, and automated routing to appropriate staff

• Allows point-of-care (“just-in-time”) integration (eg, MGH PCOI, 2004)

– E-books; Practice guidelines; Patient information; Drug information; “How To…”; Forms; Medical calculators; Referral/Access Guide; Practice Alerts

Internet Portals in Primary Care

EHR

PracticeGuidelines

PatientEducation

E-mail

E-prescribing

Billing

AppointmentsReferrals

Admissions

Internet Portals-Physician Experiences

Patient Gateway application (Partners;Harvard Hospitals)

-appointments; prescriptions; referrals; health information; communication with PCP.

“If offered reimbursement… would you be willing to email w/patients?”

Kittler AF et al Inform Prim Care 2004;12:129-38.

Point-of-Service Computerized Applications

Point-of-Service Computerized Applications

Advantages (vs. Internet)• Overcome access/language/literacy barriers• Link to EHRs w/o cyberspace (security)• Use “down-time” while patient waits for physician• Utilize/incorporate vital signs and other

measures/lab tests performed in the office• Physician can respond in real-time• Potentially bill-able

Disadvantages• Computer/IT support; glitches; hackers• Impersonal; Can’t read “body-language”

UTI PSCA in SACC-Aagaard et al, J Gen Intern Med, in press.

Validation Study: • Computer algorithm based on previously

validated telephone management algorithms.• Consecutive women with suspected UTI

complete PSCA, see clinician as usual, and have referent standard test (urine culture).– Clinician completes standardized encounter form.

• Compare eligibility for computer-assisted treatment with physician diagnosis and urine culture.

Computer Diagnosis of Uncomplicated UTI is Compatible with Physician Diagnosis

Physician Diagnoses

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**OtherVaginitisPyelonephritisUncomplicated UTI

Computer Diagnosis of UTI is Confirmed by Urine Culture in Majority (67%) of Cases

Frequency of Culture Confirmed UTIs

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UTI PSCA in SACC-Aagaard et al, J Gen Intern Med, in press.

Post-Implementation: • 182 women accessed kiosk in 2005• 56 eligible and treated by computer (31%)

– Satisfaction:• 98% easy to use• 92% think programs should be designed for other illnesses• 95% would recommend to family and friends

– Safety• No difference in return visits/recurrence or hospitalizations

– Average Encounter Time ~ 30 minutes

Potential Roles for PSCAs in Primary Care Practices• Registration• Informed Consents• Health Care Maintenance &

Prevention• Disease Screening Instruments

– HIV/STDs (Gerbert)• Acute Illness Management

– URIs & antibiotics (Gonzales); – UTI management (Aagaard); – Triage

• Chronic Disease Management– Depression Care – Diabetes Care– Chlamydia Screening– Emergency Contraception

Disruptive Innovations

“MinuteClinic will have 100 clinics operating in 10 cities by 1/1/06, and will open 300-500 over the next 3-5 years (most at CVS pharmacies)”

Other Partners: Wal-Mart, Target, Albertson’s, Rite-Aid

Business Principles

Price Visibility

Convenience

Technology

Customer Focus

Staff Motivation

-Financial Times 11/2/05.

Conclusions

• Primary Care is at a crossroads.

• Physicians work harder, increasingly hassled, and get paid less

• Patients have less access to PCPs and are paying more out-of-pocket expenses

Which Innovations Will Help Improve Practice?

Physician Patient Total

∆t Hassles Income Access Cost Costs

Internet Portal

PSCA

EHR

E-mail

Open Access

Teams

Which Innovations Will Help Improve Practice?

Physician Patient Total

∆t Hassles Income Access Cost Costs

Internet Portal

↓ ↓ ↓ ↓ ? ↓ ↓

PSCA ↓ ? ↓ ↓EHR ↔ ↓ ? ↔ ↔ ↓E-mail ? ↓ ? ↓ ↓Open Access

? ↓ ?

Teams ↓ ? ? ? ?

Thank You