1. Disruptive Innovations to Achieve Right Specialty Care February 24, 2017
Hal F. Yee Jr., M.D., Ph.D. Chief Medical Officer Los Angeles County Department of Health Services

2. Disclosure
I do not have relevant financial relationships with commercial interests.

3. GME/CE Learning Objectives
Recognize the critical importance of disruptive innovations in health care delivery.
Demonstrate how health information technology can genuinely improve the effectiveness and efficiency of health care delivery.
Recommend how the health care safety net represents a unique model for creating and testing disruptive innovations.

4. LA County DHS (ca. 2011): Some Challenges
Scale
88 cities, 10M residents, 2M uninsured
Infrastructure
Absence of unique patient/provider IDs, EHR, real primary care, standards, or coordination
Governance
Bureaucracy, politics, civil service, silos
Disparity between demand & capacity

5. Los Angeles County: Scale
Houston
Chicago
Los Angeles County: Scale
New York City
San Francisco
Philadelphia
(Optional slide): With over 4,000 square miles, Los Angeles County is larger than San Francisco (City and County), The District of Columbia, Philadelphia, Houston, Chicago, and all 5 boroughs of New York City combined.
District of Columbia
Data Source: U.S. Census Bureau, Topologically Integrated Geographic Encoding and Referencing system, Maps Drawn at 1:750,000 scale. 5 5

6. The Problems Disruptive Innovations:
Patient-Centered
Medical Neighborhood
PCMH Specialty Home
PCP
Specialist
Clear
Consistent
Coordinated
Timely
Efficient
Cost effective
Ambiguous
Inconsistent
Discoordinated
Untimely
Inefficient
Costly
Disruptive Innovations:
Specialty-primary care work groups
Expected clinical practices
Electronic consultations

7. The Solutions
Disruptive innovations: implement novel processes that greatly increase access through simplicity and cost reduction
Address key barriers to change:
technical (i.e., policies and procedures)
adaptive (i.e., culture and behavioral)

8. Specialty-Primary Care Workgroups
What is the disruption?
How does it address the technical and adaptive barriers?
Improves consistency, coordination, efficiency, and cost effectiveness.

9. Expected Clinical Practices
What is the disruption?
How does it address the technical and adaptive barriers?
Improves clarity, consistency, efficiency, and cost effectiveness.

10. Specialty-Primary Care Expected Practices
Developed by Specialty-Primary Care Work Groups composed of specialists and primary care providers
Guided by 1) real-life practice conditions, 2) available clinical evidence, and 3) the principle that we must provide equitable care for entire patient population
In individual situations a provider’s clinical judgment may vary from an Expected Practice, but in such cases compelling documentation for the exception should be provided.

11. Expected Practices: Examples
Cancer screening (e.g., breast, colon)
Evaluation and management of specific conditions
Specialty care co-management recommendations
Standard logistical information (e.g., ‘how to do X’)

12. Electronic Consultations
What is the disruption?
How does it address the technical and adaptive barriers?
Improves clarity, consistency, coordination, timeliness, efficiency, and cost effectiveness.

13. Electronic Consultation

14. Impact Ability to track, triage, advise, avoid
Wait times/Access to care
Dialog and relationship building
Elimination of illegible faxes
Improved specialist efficiencies
User experience and education

15. Bibliography
Chen, A Hm, Murphy, EJ, Yee HF Jr, eReferral - A new model for integrated care, New Engl J Med, 368:2450-3, 2013.
Yee, Jr HF, The Patient-Centered Medical Home Neighbor: A Sub Specialty Physician’s View, Ann Int Med, 154:63-4, 2011.
Soni, SM, Giboney, P, Yee, HF Jr, Development and implementation of expected practices to reduce inappropriate variations in clinical practice, JAMA, 315: , 2016.
Barnett, ML, Yee, Jr HF, Mehrotra, A, Giboney, P, Widespread adoption of electronic consultations in a large safety-net system enables rapid access to specialty care, Health Affairs, in press, 2017.