THE COMMONWEALTH FUND Perfect Care When is performance good enough? –For you; for your family Near-perfection is attainable even in health care The question.

THE COMMONWEALTH

FUND

Perfect Care• When is performance good

enough?– For you; for your family

• Near-perfection is attainable even in health care

• The question we all should be asking:– How soon can we achieve

perfect care?• Within our organization

• Across the entire health care system

THE COMMONWEALTH

FUND

An Organized Delivery System that Emphasizes Primary and Preventive Care and Is Patient-Centered

3. Emphasize Primary,

Preventive, and Patient-Centered

Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements

THE COMMONWEALTH

FUND

Expand Primary Care and Preventive Services

• Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.

– Barbara Starfield, MD

THE COMMONWEALTH

FUND

Expand Primary Care and Preventive Services

• Health is better in areas where there are more primary care physicians or more primary care services

• People who receive care from a primary care physician are healthier

• Costs of care are lower in areas where there are more primary care physicians or more primary care services

• More primary care is associated with more equitable care

Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

Shared Decision-Making:An Important Aspect of Patient-Centered Care

THE COMMONWEALTH

FUND

Why Is Shared Decision Making Important

• Combines evidence-based practice with patient preferences

• Many clinical decisions involve value judgments • Interventions have different benefits/ risks that

patients value differently • There is no single right answer for everyone • Ethical principle of patient autonomy and legal

requirement of informed consent • Health care providers cannot automatically infer

what patients value, nor can they assume what care decisions are in patients' best interest.

• Uncertain nature of clinical information

THE COMMONWEALTH

FUND

Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center

• Provides evidence-based tools to help patients understand trade-offs of medical vs. surgical treatment given their preferences

• Assists with health care decisions (e.g., videotapes, booklets, websites)

• Provides follow-up counseling with skilled staff

• Generally results in lower rates of invasive procedures once the patient understands the trade-offsKate Clay, BA, MSN,

Program Director

THE COMMONWEALTH

FUND

Being There For The Patient

• The importance of continuity

• “After-hours” care

THE COMMONWEALTH

FUND

Practice Has Arrangement for After-Hours Care to See Nurse/Doctor

81

47

76

9590 87

40

0

25

50

75

100

AUS CAN GER NET NZ UK US

Percent

2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

THE COMMONWEALTH

FUND

Increase Transparency and Reporting on Quality and Costs

4. Increase Transparency and Reporting on Quality and Costs

3. Emphasize Primary,

Preventive, and Patient-Centered

Care2. Implement Major Quality and Safety Improvements

1. Guarantee Affordable Health Insurance Coverage

THE COMMONWEALTH

FUND

NCQA/HEDIS Experience

• Ten years of measuring data has shown that measurement and public reporting leads to improvement:– Children today nearly three times more likely to

have had all immunizations as in 1997– Diabetics today twice as likely to have cholesterol

controlled (<130 mg/dL) as in 1998– More than 96% of cardiac patients prescribed bet-

blockers after a heart attack (up from 62% in 1997)

Source: NCQA, “The State of Health Care Quality 2006,” 2006.

THE COMMONWEALTH

FUND

Improvements in Use of Beta BlockersAfter a Heart Attack

Source: National Committee for Quality Assurance, The State of Health Care Quality: 2006, Washington, D.C.: NCQA, 2006.

0

20

40

60

80

100

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

90th percentile

Commercial mean

10th percentile

THE COMMONWEALTH

FUND

Expand the Use of Interoperable Information Technology

5. Expand the Use of Interoperable Information Technology

4. Increase Transparency and Reporting on Quality and Costs

3. Emphasize Primary,

Preventive, and Patient-Centered

Care2. Implement Major Quality and Safety Improvements

1. Guarantee Affordable Health Insurance Coverage

THE COMMONWEALTH

FUND

Electronic Medical Records and Information Systems

• Reduce duplicate tests• Reduce hospital admissions by

having information accessible to emergency room physicians

• Improve patient care• Provide decision support for

physicians and patients• Facilitate “referrals,” secure transfer

of responsibility• Reduce medical errors• Promote better management of

chronic conditions and care coordination– Registries– Performance information– Facilitated by interoperability

THE COMMONWEALTH

FUND

Over 80% Medication Errors Prevented with Computerized Order Entry System

Source: Adapted with permission from D.W. Bates et . al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.

26.6

51.2

142.0

74.0

0

20

40

60

80

100

120

140

160

Baseline(1992)

Period 1(1993)

Period 2(1995)

Period 3(1997)

Overall MedicationErrors (except misseddose)

1.7

7.6

7.3

1.1

0

1

2

3

4

5

6

7

8

Baseline(1992)

Period 1(1993)

Period 2(1995)

Period 3(1997)

Serious MedicationErrors (nonintercepted)

THE COMMONWEALTH

FUND

U.S. Adoption of Health Information Technology

Range: Medium orHigh Quality

Surveys

Best Estimates: High Quality Surveys

EHR: ambulatory 17% to 25% 17%

Solo practitioners

12.9% to 13% 13%

Large groups* 19% - 57% 39%

EHR: hospitals 16%† - 59%†† None

CPOE: hospitals 4% to 21% 5%

Source: Presentation by Ashish Jha. “Health IT Adoption: a cross-national comparison.” June 26, 2006.

THE COMMONWEALTH

FUND

Primary Care Practices with Advanced Information Capacity

*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care.

Percent reporting 7 or more out of 14 functions*

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

87 83

72

59

32

19

8

0

25

50

75

100

NZ UK AUS NET GER US CAN

Prescriptions1039105 = 73%Prescriptions1289023 = 87%

Disch. Letters 682923 = 85 %Disch. Letters 1054314 = 88 %

Lab. reports543040 = 82 %Lab. reports844528 = 98 %

ReferralsReferrals115597 = 60 %ReferralsReferrals

Reimbursement

21049 = 92 %

GP´s with EDI : 2150 = 98 %

Specialists with EDI: 639 = 80 %

Hospitals with EDI : 63 = 100%

Pharmacies with EDI: 331 = 100 %

Doctors on Call: 15 = 100 %

Health Insurance: 17 = 100 %

79 messages /min

Lab Requests44385 = 15 %

0 100000 200000 300000 400000 500000 600000 700000 800000 900000

1000000 1100000 1200000 1300000

92 93 94 95 96 97 98 99 20 O1 O2 O3 O4 O5 O6

MedCom -The Danish Health Data NetworkMessages/Month

Network

Source: I. Johansen, “What Makes a High Performance Health Care System and How Do We Get There? Denmark,” Presentation to the Commonwealth Fund International Symposium, November 3, 2006.

THE COMMONWEALTH

FUND

MedCom – The Danish Health Data Network

THE COMMONWEALTH

FUND

Reward Performance for Quality and Efficiency

6. Reward Performance for Quality and Efficiency

4. Increase Transparency and Reporting on Quality and Costs

3. Emphasize Primary,

Preventive, and Patient-Centered

Care2. Implement Major Quality and Safety Improvements

1. Guarantee Affordable Health Insurance Coverage

5. Expand the Use of Interoperable Information Technology

THE COMMONWEALTH

FUND

Medicare/Premier Hospital Quality P4P Demonstration

• First year results showed significant improvement; composite score increased –– AMI: 87% to 91%– Heart Failure: 65% to 74%– Pneumonia: 69% to 79%– CABG: 85% to 90%– Hip/knee replacement: 85% to 90%

• Patients receiving better care showed lower mortality (AMI, CHF)

• Cost savings for hospitals (AMI, Pneumonia, CABG, Hip/Knee) and Medicare

THE COMMONWEALTH

FUND

95

7972

58

43 41

30

0

25

50

75

100

UK NZ AUS NET GER CAN US

Percent reporting any financial incentive*

Primary Care Doctors’ Reports of Any Financial Incentives Targeted on Quality of Care

*Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

THE COMMONWEALTH

FUND

Encourage Public-Private Collaboration to Achieve Simplification,

More Effective Change

7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change

4. Increase Transparency and Reporting on Quality and Costs

3. Emphasize Primary,

Preventive, and Patient-Centered

Care2. Implement Major Quality and Safety Improvements

1. Guarantee Affordable Health Insurance Coverage

6. Reward Performance for Quality and Efficiency

5. Expand the Use of Interoperable Information Technology

THE COMMONWEALTH

FUND

There Has To Be Leadership

• Federal laggership• Collaborating public-

private groups can lead– IHA (California)– MHQP (Massachusetts)– HQA, AQA– IHI’s new 5 million lives

campaign

THE COMMONWEALTH

FUND

IHA (Integrated Healthcare Association) - California

• Collaboration of multiple stakeholders with a neutral convener– Purchasers – Pacific Business Group on Health – California Association of Physician Groups (225) – California health plans (7) – Consumer Groups – State of California Department of Managed Health

Care & Office of the Patient Advocate– California HealthCare Foundation – Rewarding

Results grant– NCQA (National Committee on Quality Assurance)

THE COMMONWEALTH

FUND

IHA - California

Agreement on measures (technical quality, patient experience, use of health information technology)

• Competitive stakeholders can collaborate on aligning incentives

Agreement to tie P4P to the common measures; but no attempt to agree on payment formulae

Results• Year over year improvement• Scatter in performance

– This isn’t sufficient to achieve perfection

THE COMMONWEALTH

FUND

Massachusetts Health Quality Partners (MHQP)

• MHQP– A broad-based coalition of physicians, hospitals, health plans,

purchasers, and government agencies– Seeks to improve health care through collaboration among all

stakeholders– Common quality agenda, including shared guidelines and

tools, as well as becoming a source for comparative health quality information

• Public Reporting– In 2006, started Medical Group level reporting of 15 quality

measures and patient satisfaction measures– Moving forward, will incorporate Medicare/Medicaid data

(designated as one of the 6 Ambulatory Quality Alliance pilots)– Beginning to explore new efficiency measures and their role in

public reporting

THE COMMONWEALTH

FUND

Achieving a High Performance Health System: What You Can Do

THE COMMONWEALTH

FUND

• What You Must Do– Take An Active Role In Improving Your Own Care – Take An Active Role In Improving Care In Your

Health System– See The Positive Side To Change

• What We All Must Stop Doing– Protect Our Turf (there is still a lot of turf to go

around)

THE COMMONWEALTH

FUND

Achieving a High Performance Health System: What You Can Do

• Advocate for affordable health insurance for all • Establish and publicize policy on discounted care for uninsured and

low-income• Invest in chronic care improvement, transitional care• Share and help spread best practices; join collaboratives to

implement proven quality and patient safety measures• Improve patient-centered care; survey and respond to patient

concerns• Support transparency; public reporting of clinical quality, patient-

centered care, and efficiency• Accelerate adoption of IT; ensure patient access to an integrated

personal health record • Participate in demonstrations that reward high quality and efficient

care; be actively involved in design of incentivized payment systems• Consider options for better coordination and integration of care

delivery; shared accountability for patient care through physician-hospital organizations; accountable medical homes

THE COMMONWEALTH

FUND

Thank You!Karen Davis, President, The Commonwealth Fund

Anne Gauthier, Senior Policy Director, Commission on a High Performance Health System, The Commonwealth Fund

Tony Shih, MD, Senior Program Officer, Quality Improvement and Efficiency, The Commonwealth Fund

Elizabeth Sturla, Executive Assistant, The Commonwealth Fund

THE COMMONWEALTH

FUND

Visit the Fund

www.cmwf.org