Transcript Future Steps: Chronic Care Management

Improving Quality and Efficiency in Primary Health Care:
Reflections on ‘Engineering’ People and Processes
R. Van Harrison, PhD
Professor of Medical Education
University of Michigan Medical School
Overview
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Personal background and viewpoint (bias?)
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Frameworks: living systems; health care, physicians
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GUIDES: improving primary care
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Efforts to involve physicians in process change
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Implications for IOE graduates?
Levels of Living Systems: A Framework
Levels
– Supernational
– Society
– Organization
– Group
– Individual
– Organ
– Cell
• Within each level: inputs,
processes, and outputs
• Subsystems to process
matter/energy and information
• Outputs at one level can
become inputs at another
level
Miller JG. Living Systems. New York:
McGraw-Hill, 1978
Focus of Traditional Disciplines
Levels of
Living Systems
Theoretical
Disciplines
Applied
Disciplines
– Supernational
– Society
Sociology
– Organization
Business
– Group
– Individual
Psychology
Education
– Organ
Biology
Medicine
– Cell
Elements of a Health Care System
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Public health and preventive medicine
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Emergency medical care
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Ambulatory care: simple, complex
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Inpatient care: simple, complex
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Long term, continuing care
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Care for emotional and developmental problems
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Transportation and access
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Financial compensation for disability
Physicians
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Education and training
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88 specialties and subspecialties (7 – 10 yrs training)
Expertise: biological process, diagnosis & treatment
No organizational training; role model work from residency
Enormous ongoing flow of new biomedical knowledge
Roles
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Culture: independence, latitude of discretion
Views of needs for diagnosis & treatment drives organization
(clinical vs. administrative roles; power bottom-up or up-down)
Decide, expect someone will make happen (admin another role)
55 hrs/wk [UMHS], multiple responsibilities, clinical precedence
Physicians (continued)
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Perceptions and learning
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National structural issues
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Overestimate aggregate patient status (encounter vs. individual)
Perceptions: case vs. population effect; specialty differences
Very fast learners, typical presentation too slow (time pressure)
Over half practice in groups of ≤ 6 physicians
Electronic medical records – < 25% have, no “good” one
Physician practice and payments are separate from hospital
Unusual for physicians and hospital to be in one corporate
structure (e.g., only 25% of medical schools; training context)
UMHS engaging physicians in QI
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Early 1990’s UMHHC “Total Quality Program” did not include
2005 UMHS “Michigan Quality System” includes
Financial Structure/Incentives
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Fee-for-service – until late 1980’s, always the more you
do the more you are paid.
Fixed payments – in late 1980’s and early 1990’s, many
fixed hospital (DRGs) and per patient (capitation)
payments: the more you do the less you have left
What should be done?
What should not be done?
How to do what should be done most efficiently?
Increasing Physician Workload
For a primary care physician with a typical panel of
2,500 patients, providing recommended:
Preventive care (USPSTF) = 7.4 hrs/work day*
Chronic care (10 conditions) = 7+ hrs/work day**
Total =
14+ hrs/work day
+ Acute care (done first!)
* Yarnall et al, Am J Public Health 2003; 3:209
** Ostbye et al, Annals of Fam Med 2005; 3:209
GUIDES
(now in Outcomes Management Program)
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1992–1995 UMHS expanded its primary care operations
and purchased several primary care practices in the area
(feeder system for specialized care under capitation)
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1996 UMHS created Guidelines Utilization,
Implementation, Development, and Evaluation Studies
(GUIDES) unit
Objectives
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Develop guidelines – institutional consensus
Provide materials for uniform education
Decrease practice variation
Measure quality of care
Achieve innovation by new methods of care
Decrease cost
Meet JCAHO requirements
Provide clinical leadership
GUIDES Organization and Funding
1.0 FTE faculty
3.0 FTE staff
$400,000 budget
1/3 guidelines
2/3 measurement
& improvement
Guideline Development
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Teams composed of all constituent specialties
but team leads typically from primary care
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Initial target audience - primary care
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Evidence based literature review
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Guidelines presented to each constituent clinical
department for review
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Final review by Executive Committee for Clinical
Affairs at UM Hospitals & Health Centers
Format
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Key points readily accessible
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Tables and figures emphasize essential
recommendations
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SOR/LOE for all key points (recently added)
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Deviation from national guidelines noted when
present
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Annotated bibliography
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Memo on incremental changes with each revision
Content
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24 guidelines developed and updated
Topics chosen by guideline oversight team:
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institutional priorities
national priorities (HEDIS)
high volume conditions
no practical guideline available
Updates each 5 years
Interim revisions when new evidence dictates
(e.g., PIOPED II affecting VTE guideline)
UMHS Current Guidelines
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Adult Immunizations
ADHD
Allergic Rhinitis
Asthma
Breast Problems
Cancer Screening
Coronary Artery Disease
Constipation & Soiling in Children
Depression
Diabetes Mellitus
GERD
Heart Failure
Hypertension
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Knee Pain
Lipid Screening & Management
Low Back Pain
Osteoporosis
Otitis Media
Peptic Ulcer Disease
Pharyngitis
Prenatal Care
Rhinosinusitis
Smoking Cessation
Urinary Tract Infection
Venous Thromboembolism
Dissemination
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Electronic dissemination to relevant constituents
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Posting on University of Michigan clinical web page and
available to internal and external physicians
[external: www.med.umich.edu/1info/fhp/practiceguides/ccg.html]
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Patient handouts available at guideline link
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On-line CME available for all guidelines
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National Guideline Clearinghouse posting
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Formerly reviewed by and disseminated to panel of
community physicians as part of HMO adoption
Performance Measurement
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Develop multipayor chronic disease registries
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Collect relevant clinical information
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Report information to provider & patient
• Identify a responsible provider
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Modify delivery system to improve care
Step 1
Establish a chronic disease registry
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Identify patients with the chronic condition
• Medications
• Billing records
• Problem summary lists
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Avoid "false positives"
• Women on metformin for polycystic ovarian syndrome
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Establish criteria for "your patients"
• Two visits in two years
 Identify provider responsible for patient
Step 2
Collect relevant clinical information
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What are national or regional quality criteria
• National Quality Forum (NQF)
• Michigan Quality Improvement Consortium (MQIC)
• Health Plan Employer Data Information Set (HEDIS®)
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Who will do it
• Identify competent dedicated data analyst(s)
with access to necessary information
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What types of information
• Lab data (A1c, LDL)
• Physical Exam (foot, eye)
• Healthcare providers
• Medications (ACE)
Step 3
Reporting
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Monthly high priority patient reports sent to nursing and
pharmacists for case management
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Semi-annual physician, health center comparative, and
leadership reports
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Discussed at health center and department leadership meetings
to determine resource allocation, educational needs
Incorporated into physician annual performance evaluation
Report to provider on individual patients (CHF)
 Prioritize report and highlight items needing attention
 Decide whether to use color or black & white ($$$)
Reports Comparing Physicians (statins)
Report aggregated information
to leadership (CHF)
Primary Care only (N= 933)
Geriatrics only (N= 133)
June 2007
Cardiology only (N= 1615)
Jointly managed (N=1502)
June 2006
December 2005
Quality Improvement:
Steering Committee for Diabetes
Physician Leaders
(Gen Med, Fam Med,
Endocrine, Geriatrics)
Ambulatory Care
Services
Guidelines Outcomes Management
Pharmacists
Diabetes Mellitus
Steering Committee
Quality Improvement
Office
Nursing
Diabetes Educators
Educate providers and staff on
improving clinical documentation
Click on:
• Diabetes eye exam
Click on:
• Foot exam – visual,
sensory, pulses
Click on:
• Self-management goal
Then enter the goal in
"Additional information"
Support
Provider
 Report detailed clinical
data to the provider at
patient's visit via an
automated system
 Identify items that need
attention; then provide
detailed action steps
 Work with staff to divide
work & responsibilities
Support
Patient
 Activate and educate
patients by providing
them with information
on how they are
doing at the time of
their visit
 Insert patient data
onto a take-home
educational sheet
Automated Reminder Letters
Dear John Smith,
At the East Ann Arbor Health Center, we want you to have the best
diabetes care. To improve our care and to keep our medical record
up-to-date, we are sending this letter with information regarding
diabetes-related tests and exams…. After reviewing your medical
record, we have the following recommendations:
 Please take the enclosed slip to the lab for a:
blood test to check your average sugar control (A1c)
blood test to check your cholesterol levels
urine test to check your kidneys
You do not have to fast for this test. We will contact you about the
results and suggest follow-up if needed.
Using the Multi-disciplinary Team
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Medical assistants print daily actionable reports,
support action items, point of care A1c testing,
enter data into EMR; perform monofilament exam
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Pharmacists assist with medication intensification
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Nurses identify and address barriers to care for
high priority patients
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Screen for depression, health literacy, medication adherence,
financial barriers
Spreading Innovations
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Horizontal from pilot clinics to the remaining
fourteen primary care health centers
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Vertical from the primary care clinics to geriatric
and endocrine specialty clinics
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131 PCPs, 157 residents
Standardize practice at the health centers
Involvement of the multi-specialty team members assist in
implementation
Across conditions from diabetes to other chronic
conditions with registries (asthma, CAD, CHF)
University of Michigan Diabetes
Performance, 2004-2007
June 2004
June 2007
Enhancing Organization & Culture
– Through GUIDES
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Broad, long-term vision for improving primary care
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Guideline development
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Institutionally shared view of whole process and interrelationships
Team members – learn to develop and integrate whole view
Measures and their use
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Sequence: guidelines, measurement, improvement (cycles)
Develop abilities, build infrastructure, standardize processes
Coordinate across departments and units (“silos”)
Physicians “see” own practice and comparisons, changes over time
Enhanced alignment of priorities across organization and over time
Improvement efforts
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Multi-specialty and multi-discipline analysis of priorities and possibilities
Pilot efforts engage individuals and groups in innovation
Roll-out involves all involved in broad view of system change and benefit
Enhancing Organization & Culture
– Through GUIDES (continued)
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Improving the improvement process
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Dealing with evolution of circumstances over time
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Changes in internal infrastructure, e.g., electronic medical records
External changes, e.g., reimbursement, pay-for-performance, new drugs
Support related institutional priorities
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Guidelines – development process, content, format, dissemination, maintenance
Measures – data bases, analyst’s skills, presentation for use
Interventions – coordination, parallel approaches for common problems
Education of residents and medical students – guidelines, systems approach
Physician recertification and demonstration of performance improvement
Societal level: demonstrate care quality, innovation
Support a fundamental strategic institutional imperative:
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Transform how people “see” their work, roles, and responsibilities in order to:
Enhance the institution’s ability to survive and thrive in a changing environment
National Efforts to Engage Physicians in
Quality & Efficiency Improvement
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ACGME (residents) – system-based practice
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ACCME (CME) – outcome of education
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AMA (CME credit) – credit for participating in QI
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ABMS (specialty recertification) – performance in practice
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FSMB (licensure) – position paper
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Joint Commission – hospital QI, medical staff
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Payer financial incentives – pay-for-performance, PQRS
[UMHS: Demo projects with BCBS-Michigan and Medicare, $3 million annually]
(Assume local knowledge and infrastructure will develop)
Implications for IOE and Health Care
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