Practice Innovations: Which Ones Will Help?

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 Nation’s Health Care: A Report from the American College of Physicians January 30, 2006

10. ACP Response(2006) • 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) • 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) • 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 • 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 21st Century Practice “Innovations” • Open (Same Day) Access • Primary Care Teams • Collaborative Care Model; Patient self-management • e-Prescribing • Electronic Health Record • New Types of Clinical Encounters • Email; Internet; Kiosk

15. Open AccessWhat Is It? Core Principle: If capacity = demand, then patients can use a same day app’t 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 AccessDoes 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 CenterAfter Open-Access System Adopted

18. Days until next available appointmentHealthcare Partners

19. Open AccessWhat 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 weren’t 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. 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 Management of Complex Patients

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

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: It’s going to happen…

26. Will EHRs Enhance Primary Care Practice? 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. Pizziferri L et al. J Biomed Inform 2005;38:176-88. (HealthPartners) *Only 29% believed LMR used equal or less time than paper documentation.

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

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

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 E-mail Patient Education E-prescribing EHR Practice Guidelines 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. Point-of-Service Computerized Applications 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; Can’t read “body-language”

36. 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.

37. Computer Diagnosis of Uncomplicated UTI is Compatible with Physician Diagnosis

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

39. 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

40. 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

41. 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, Albertson’s, Rite-Aid Business Principles Price Visibility Convenience Technology Customer Focus Staff Motivation -Financial Times 11/2/05.

42. 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

43. Which Innovations Will Help Improve Practice?

44. Which Innovations Will Help Improve Practice?

45. Thank You