Transcript 30031

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
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
3. Emphasize
Primary,
Preventive, and
Patient-Centered
Care
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
Kate Clay, BA, MSN,
Program Director
•
Provides evidence-based tools to
help patients understand tradeoffs 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 tradeoffs
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
Percent
100
95
81
90
87
76
75
47
50
40
25
0
AUS
CAN
GER
NET
NZ
UK
2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
US
THE
COMMONWEALTH
FUND
Increase Transparency and Reporting on
Quality and Costs
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
3. Emphasize
Primary,
Preventive, and
Patient-Centered
Care
4. Increase
Transparency and
Reporting on
Quality and Costs
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 betblockers after a heart attack (up from 62% in 1997)
THE
COMMONWEALTH
FUND
Source: NCQA, “The State of Health Care Quality 2006,” 2006.
Improvements in Use of Beta Blockers
After a Heart Attack
100
80
60
40
90th percentile
Commercial mean
10th percentile
20
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
THE
COMMONWEALTH
FUND
Source: National Committee for Quality Assurance, The State of Health Care Quality: 2006, Washington, D.C.: NCQA,
2006.
Expand the Use of Interoperable
Information Technology
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
3. Emphasize
Primary,
Preventive, and
Patient-Centered
Care
5. Expand the Use of
Interoperable Information
Technology
4. Increase
Transparency and
Reporting on
Quality and Costs
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
160
140
142.0
Overall Medication
Errors (except missed
dose)
120
8
7.6
7.3
7
Serious Medication
Errors (nonintercepted)
6
100
5
80
74.0
60
4
3
51.2
40
26.6
20
1.7
2
1.1
1
0
Baseline
(1992)
Period 1
(1993)
Period 2
(1995)
Period 3
(1997)
0
Baseline
(1992)
Period 1
(1993)
Period 2
(1995)
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.
Period 3
(1997)
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COMMONWEALTH
FUND
U.S. Adoption of Health Information Technology
Range: Medium or
High Quality
Surveys
Best Estimates:
High Quality Surveys
EHR: ambulatory
17% to 25%
17%
Solo
practitioners
Large groups*
12.9% to 13%
13%
19% - 57%
39%
EHR: hospitals
16%† - 59%††
None
CPOE: hospitals
4% to 21%
5%
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COMMONWEALTH
FUND
Source: Presentation by Ashish Jha. “Health IT Adoption: a cross-national comparison.” June 26, 2006.
Primary Care Practices with Advanced
Information Capacity
Percent reporting 7 or more out of 14 functions*
100
87
83
72
75
59
50
32
19
25
8
0
NZ
UK
AUS
NET
GER
US
*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.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians
CAN
THE
COMMONWEALTH
FUND
MedCom–-The
Danish
Health Data
NetworkData Network
Network
MedCom
The
Danish
Health
Messages/Month
1300000
1200000
1100000
1000000
900000
800000
700000
600000
500000
400000
300000
200000
100000
0
GP´s with EDI :
Prescriptions
1039105 = 87%
1289023
73%
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 %
Disch. Letters
682923 ==85
1054314
88%
%
79 messages /min
Lab. reports
543040 = 98
844528
82 %
Referrals
115597 = 60 %
Reimbursement
21049 = 92 %
92
93
94
95
96
97
98
99
20
O1
O2
O3
O4
O5
O6
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.
Lab Requests
44385 = 15 %
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COMMONWEALTH
FUND
Reward Performance for Quality and
Efficiency
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
3. Emphasize
Primary,
Preventive, and
Patient-Centered
Care
5. Expand the Use of
Interoperable Information
Technology
4. Increase
Transparency and
Reporting on
Quality and Costs
6. Reward Performance for
Quality and Efficiency
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
Primary Care Doctors’ Reports of Any Financial
Incentives Targeted on Quality of Care
Percent reporting any financial incentive*
100
95
79
72
75
58
50
43
41
30
25
0
UK
NZ
AUS
NET
GER
CAN
*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
US
THE
COMMONWEALTH
FUND
Encourage Public-Private
Collaboration to Achieve Simplification,
More Effective Change
1. Guarantee Affordable Health
Insurance Coverage
2. Implement Major
Quality and Safety
Improvements
5. Expand the Use of
Interoperable Information
Technology
4. Increase
Transparency and
Reporting on
Quality and Costs
6. Reward Performance for
Quality and Efficiency
3. Emphasize
Primary,
Preventive, and
Patient-Centered
Care
7. Encourage
Public-Private
Collaboration
to
Achieve
Simplification,
More
Effective
Change
THE
COMMONWEALTH
FUND
There Has To Be Leadership
• Federal laggership
• Collaborating publicprivate groups can lead
–
–
–
–
IHA (California)
MHQP (Massachusetts)
HQA, AQA
IHI’s new 5 million lives
campaign
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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)
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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
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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, patientcentered 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 physicianhospital 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
THE
COMMONWEALTH
FUND