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

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

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

2 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

3 Primary Care circa 1991

4 Primary Care circa 2006

5 Problems Facing Primary Care Increased Time Pressure Increased Hassle Factor Declining Income

6 (Time) Pressure Cooker For 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)

7 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.

8 Primary Care Physician Incomes Are Decreasing

9 The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nations Health Care: A Report from the American College of Physicians January 30, 2006

10 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

11 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

12 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…

13 Assessing Practice Innovations Physician 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?

14 The 21 st Century Practice Innovations Open (Same Day) Access Open (Same Day) Access Primary Care Teams Primary Care Teams Collaborative Care Model; Patient self- management Collaborative Care Model; Patient self- management e-Prescribing e-Prescribing Electronic Health Record Electronic Health Record New Types of Clinical Encounters New Types of Clinical Encounters Email; Internet; Kiosk Email; Internet; Kiosk

15 Open Access What Is It? Core Principle: If capacity = demand, then patients can use a same day appt 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.

16 Open Access 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.

17 Alaska Native Medical Center After Open-Access System Adopted

18 Days until next available appointment Healthcare Partners

19 Open Access 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 werent 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

20 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

21 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

22 Innovations in Process of Care Telephone management Telemedicine e-Prescribing Electronic Health Record E-mail management Internet (portal) management Point-of-service computerized applications

23 e-Prescribing Retail Pharmacy Computer or PDA EHR PBM RxHub Sure-Scripts Mail-Order Eligibility; Formulary; Benefits Drug interactions Safety monitoring Compliance

24 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

25 Electronic Health Records Benefits –Legibility –Accessibility in time and space –Quality Measurement –Patient Safety/Medical Errors –Billing Bottom-Line: Its going to happen…

26 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.

27 Do EHRs Improve Health Care Outcomes? SettingCondition ProcessOutcome EHR vs. no-EHR OConnor, 2005 HealthPartners Diabetes A1c testing No A1c control EHR decision support Sequist, 2005 Partners Diabetes OR=1.3not measured CAD OR=1.25not measured Tierney, 2003 Regenstrief CAD/CHF No No QOL, visits, cost, satisf. Feldstein, 2006 Kaiser Warfarin CI drugsnot measured Feldstein, 2006 Kaiser Bone Fx BMD; Rx

28 EHRs in Primary Care Primary Care Record Hospital Pharmacy Insurers Health Dept Nursing Home Hospital Pharmacy Insurers Health Dept Nursing Home

29 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

30 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

31 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

32 Internet Portals in Primary Care EHR Practice Guidelines Patient Education E-mail E-prescribing Billing Appointments Referrals Admissions

33 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.

34 Point-of-Service Computerized Applications

35 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; Cant read body-language

36 POS Computerized Applications Decision-Support (Couplers®) Apkon M et al. Arch Intern Med. 2005;165:2388-2394 No difference in overall screening/prevention activities Greater lab/pharmacy use in Coupler patients Provider Response –83%: Coupler use involves too much time. –70%: Coupler provides little/no marginal benefit in medical decision making or overall benefit to patients.

37 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.

38 Computer Diagnosis of Uncomplicated UTI is Compatible with Physician Diagnosis

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

40 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

41 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

42 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, Albertsons, Rite-Aid Business Principles Price Visibility Convenience Technology Customer Focus Staff Motivation -Financial Times 11/2/05.

43 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

44 Which Innovations Will Help Improve Practice? PhysicianPatientTotal tHasslesIncomeAccessCostCosts Internet Portal PSCA EHR E-mail Open Access Teams

45 Which Innovations Will Help Improve Practice? PhysicianPatientTotal tHasslesIncomeAccessCostCosts Internet Portal ? PSCA? EHR ? E-mail ? ? Open Access ? ? Teams ?? ??

46 Thank You

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