Jim Tufano, PhD, MHA University of Washington and Group Health Research Institute

1. Provider Perspectives on Information & Communication Technologies in Patient-Centered Care Redesign Jim Tufano, PhD, MHA University of Washington and Group Health Research Institute September 16, 2009 2009 AHRQ National Conference

2. Information & communication technologies (ICT) that I study • Clinical information systems/EMRs • + provider/provider clinical messaging • + patient Web portals • + patient/provider secure messaging • Electronic health risk appraisals & clinical assessment surveys • Personal health records & applications • Mobile and desktop • “Standalone” and provider-supported

3. ICT in patient-centered care: studies of provider experience • Setting: Group Health Cooperative • Member-governed non-profit financing & delivery system • 26 owned clinics (20 Puget Sound region), 7 hospitals, 860 employed MDs, 560,000 patients • EpicCare, MyChart, HealthProfile eHRA in production • *~55% of patients (308K) currently use Web portal; ~30% of primary care encounters are online • Patient-centered care redesign interventions • Access Initiative organizational redesign (2000-06) • Patient-Centered Medical Home pilot (2007-09) • Study designs and methods • Qualitative arms of 2 mixed-methods evaluation studies using semi-structured interviews (n=38 providers) *Source: unpublished Group Health administrative data

4. ICT in care redesign: the Group Health Access Initiative • Organization-wide redesign to implement the Patient-Centered Access care model (Berry et al, 2003) to better meet patients’ needs and preferences for access to care • Patient Web access (MyGroupHealth portal) • Open Access appointment scheduling • Primary care redesign/staffing model changes • Direct access to specialists (no gatekeeping) • Physician payment reform/variable compensation • Concurrent phased implementation of EpicCare Ambulatory EMR with MyChart • Incremental phased approach to care redesign and ICT implementation & integration with care processes (2000-2006)

5. Provider perspectives on ICT in the Access Initiative Theme 1: Improved quality of care (acute) Theme 2: Compromised focus on population health and chronic care Theme 3: Improved patient satisfaction Theme 4: Increased MD workload and inhibited their pace of work Theme 5: Affected quality of patient/provider interactions (both + and –) Theme 6: Decreased MD satisfaction Theme 7: PCA model unsustainable as- implemented Source: J. Tufano, Doctoral Dissertation, 2009

6. Access Initiative: effects on patient-provider interactions • “It [secure messaging] is making the patient feel like they have a stronger connection, and ultimately I think that's a good thing.” • “I don't think communication is quite as focused. You get distracted by putting in orders and finding diagnoses to link with the orders, link with the medications or whatever you order.” • “…the relationship between the patient and the primary care doc, which I think has really gotten diluted with a lot of these initiatives… I don't think fracturing those relationships has been anybody's goal with these initiatives, but I think it's nonetheless been an unintended result just because of how fragmented things get when we're always running to catch up.” Source: J. Tufano, Doctoral Dissertation, 2009

7. Access Initiative: summarized provider experience “The net effect of these initiatives has been to totally change every work process that we do… No, I would not want to go back, but that doesn't mean that things are okay as they are. The burnout rate among my colleagues is huge and I think that those of us that have managed to retain some semblance of balance do it by almost unacceptable levels of compromise. Either for ourselves and our personal time, or what we define as good enough care… We didn't get to where we are today by saying ‘Ah, easy come, easy go, I’m doing the best I can, and if I don't feel like it, well, you know’ - that's not what we're here for… The burden of multi-tasking that Epic and secure messaging and our appointing schedules for three patients an hour requires is really punishing… I'm exhausted… Something's gotta give somewhere.” Source: J. Tufano, Doctoral Dissertation, 2009

8. ICT in care redesign: the Group Health PCMH pilot • Single clinic implementation of the Patient-Centered Medical Home (PCMH) care model (2007-2009) • Pilot involved 8 adult primary care physicians, their staff, and their ~11,000 adult patients • Precursors: panel sizes reduced, MD salaries fixed, staffing increased, appointments lengthened • Comprehensive and participatory approach to PCMH care model design & implementation • Intervention specified use cases for pre-existing ICT mapped to care team member roles & responsibilities

9. Provider perspectives on ICT in the PCMH pilot Theme 1: Contributed to better care across full continuum of preventive-chronic-acute Theme 2: Stronger patient connections Theme 3: Promoted and reflected teamwork Theme 4: Contributed to a supportive work environment Theme 5: Enabled proactive provider information seeking and information sharing Theme 6: Improved provider job satisfaction Theme 7: ICT are necessary and sufficiently- designed Source: J. Tufano, Doctoral Dissertation, 2009

10. PCMH pilot: effects on patient-provider interactions • “The net effect is a positive effect in getting patients' questions answered… And they do feel more connected with the doctor, because he or she responds… They're getting a response from the team. And they really like that connection… So there's a better connection I think with the team with the electronic chart and all the secure messaging… I'm developing stronger ties… They understand their illnesses better, and they're better able to follow through on the treatments… [Office visits are] time that's better spent.” • “There is no way I can directly ask some questions, but now that I have the tools I can say like ‘Hey, you mentioned in your Health Profile that you're drinking a little bit more alcohol, so how about – what’s happening?’ So I have a starting point there and then I can kind of ask them and get them into an intervention.” Source: J. Tufano, Doctoral Dissertation, 2009

11. PCMH pilot: summarized provider experience “I'm finally able to do everything that I learned family practice docs are supposed to do. And I even do more than I thought I could do… I think we all know this is the right way to do medicine so we want to make sure our patients always have that experience. We're really focused on our patients, making sure that the service and quality of care is always there… I'm using [the ICT] much more extensively and leveraging them more, taking more time to use them. Looking for opportunities for me to change something, intervene, plan ahead. As opposed to in the past… I just basically, whatever they presented me in the office with, that was pretty much – I tried to get through that, I felt lucky for that… And then trying not to create more issues for patients to bring up. Whereas now I will ask them ‘is there anything else?’ or ‘what about your preventive screening?’” Source: J. Tufano, Doctoral Dissertation, 2009

12. Key conclusions and potential policy implications • PCMH practice certification criteria (NCQA, CMS) should be revised • Access Initiative clinics and the PCMH pilot clinic would likely be classified as Tier 3 medical homes, but… • interventions created sharply contrasting provider experiences and assessments of care quality and patient experience • Key determinants of provider adoption of ICT (perceived usefulness and consequences associated with use): • are defined contextually (e.g., by care model, by approaches to care redesign/ICT implementation) • can vary widely with the same ICT used in the same setting • Ensuring optimal contexts for ICT implementation and support is critical to achieving goals of PC care reform