Disruptive Innovations to Achieve Right Specialty Care February 24, 2017

1. Disruptive Innovations to Achieve Right Specialty CareFebruary 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 Chicago Houston New York City San Francisco Philadelphia District of Columbia Data Source: U.S. Census Bureau, Topologically Integrated Geographic Encoding and Referencing system, 2009. Maps Drawn at 1:750,000 scale. 5

6. The Problems 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 CareExpected 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, 315:2163-64, 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.