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Engines of Success for U.S. Health Reform?
Key to High Performing Health Care Organizations?
Eric B. Larson, MD, MPH Vice President for Research, Group Health Executive Director, Group Health Research Institute
Learning Health Care Systems
AIAMC I Joint Executive Management /Research Forums I March 21, 2013
Why this topic? Why today?
1999 2001
The IOM planted the idea of “learning health care systems” more than a decade ago to solve the quality crisis.
More than a decade later…
We are still struggling to achieve “the triple aim”:
• Improving patient experience (quality & satisfaction)
• Improving the health of populations (better access)
• Reducing per capita cost
4
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$2,000
$4,000
$6,000
$8,000
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2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
US Health Care System Theoretical Waste(Aggregate Waste 2011 - 2019)
1. Overtreatment 2. Failures to Coordinate Care 3. Failures in Care Delivery
4. Excess Administrative Costs 5. Excessive Health Care Prices 6. Fraud and Abuse
Total U.S. health care system waste = $11 trillion over 9 years
Berwick & Hackbarth on the problem: Systemic wedges of waste (JAMA 2012)
What can be done?
Today’s system appears wedded to prevailing payment arrangements.
Powerful forces have a strong stake in preserving the status quo. (“It works for us.”)
Must we accept poor quality, lack of access, higher costs?
Some doubt the U.S. health care system can change itself:
• Stanford economist Victor Fuchs in The New York Times: The only solution may be change that profoundly “unsettles established interests.”
• He quotes Alexis de Tocqueville: In the U.S., “events can move from the impossible to the inevitable without ever stopping at the probable.”
Can learning health care systems be the engines of change?
Overview of today’s talk:
• History and development of a learning health care system (LHCS): Group Health Cooperative
• Potential opportunities for research in LHCS
• What we’ve learned about LHCS: Challenges & rewards
• How LHCS can help solve the crises in quality, access, cost
The challenges. The opportunity.
The IOM’s 2008 Roundtable on Evidence-Based Medicine identified problems with U.S. health care:
• Evidence is often not available for clinical decision making.
• Uptake of new discoveries can be slow and false starts are common.
• Even when evidence is available, it is not applied consistently—meaning variation, inefficiencies, and disparities persist.
Opportunity:
• We need a new clinical research paradigm.
• We need “learning health care systems.”
What is a learning health care system?
The IOM’s vision:
• Research happens closer to clinical practice than in traditional university settings.
• Scientists, clinicians, and administrators work together.
• Studies occur in everyday practice settings.
• Electronic medical records are linked and mined for research.
• Recognition that clinical and health system data exist for the public good.
Evidence informs practice and practice informs evidence.
Today’s Group Health
A Seattle-based health plan serving 620,000 in Washington, Idaho
Combines health care and coverage
1,200 physicians and 9,500 staff
Nearly 2/3 of members get care at Group Health facilities
Annual revenue: about $3.3 billion
Includes Group Health Research Institute
Research is in Group Health’s DNA
1947: Group Health’s original mission statement: “Contribute to medical research”
1950s-70s: University-based researchers mine Group Health data beginning in 1956 with the Seattle Longitudinal Study on Aging, Boston Collaborative Drug Study.
1983: Group Health Research Institute (GHRI) founded with Ed Wagner, MD, MPH, as director
Highlights of GHRI’s first 25 years
Registries for breast cancer screening and immunization
• 1987: The nation’s first breast cancer screening registry and reminder system
• 1991: 1 of 4 sites in the CDC’s first Vaccine Safety Datalink
• JAMA 1995: 32% reduction in late-stage breast cancer and 89% of 2-year-olds have complete immunizations
• Both registries enable ongoing large-scale research that impacts clinical recommendations and national standards
The Chronic Care Model
• Developed at GHRI’s MacColl Center for Health Care Innovation as a way to improve diabetes care and outcomes
• Now used worldwide for diabetes, depression, congestive heart failure, asthma, and other chronic conditions
Challenge: Linking research to practice and vice versa
2002 “Access Initiative”
• Group Health has always been primary-care based; aspired to be patient-centered.
• Reputation and past performance in “managed care” and as a traditional HMO: Access was a problem.
Access Initiative elements included:
• Same-day appointments • Open access to specialists • A new EMR with secure website for members • Ambitious productivity standards • Reimbursement change
Challenge: Linking research to practice and vice versa
University of Washington/Group Health study of “Access Initiative” showed:
• Increased patient satisfaction • Markedly improved access and productivity • But no gains in clinical quality, and • A dramatic negative impact on primary care provider work life
Next step: • Patient-centered medical home pilot • Can it improve quality and revitalize primary care? • Our design benefitted from “lessons learned” through the
Access Initiative
Patient-centered medical home to revitalize primary care
Genesis of medical home concept: Special-needs pediatrics and internal medicine
Reinvigorated core attributes of primary care
More system support for chronic illness care
Advanced information technologies (EMR, registries, reminders, patient portals)
Supportive physician payment methods (promotes medical home goals, not simply volume)
Patient centered medical home to revitalize primary care
Design principles for Group Health’s pilot:
• Panel size reduced from 2,300 to 1,800 patients
• Appointment times increased from 20 to 30 minutes
• Expanded multi-disciplinary clinical teams
• Desktop time for physicians
• E-technology and communication (EMR and secure e-mail with patients)
Reid RJ et al, Health Affairs 2010;29(5):835-43 Larson EB et al, JAMA 2010; 306(16):1644-45 Reid RJ et al, Am J Manag Care 2009;15(9):e71-87
2-year evaluation shows positive results
Patient experience in the medical home
Significantly higher scores for patients at pilot clinic Year 1
Year 2
Quality of patient-doctor interactions
Shared decision making
Coordination of care
Access
Helpfulness of office staff
Patient activation/involvement
Goal setting/tailoring
Compared to controls:
Difference not significant
Medical Home higher
Medical Home lower
Staff experience in the medical home
Marked improvement in burnout levels at prototype clinic at 1 year
25.6%
18.2%
30.4%
25.0%
54.5%
54.2%
10.0%
25.0%
18.8%
25.0%
19.4%
44.4%
-60% -40% -20% 0% 20% 40% 60%
12 month
Baseline
12 month
Baseline
12 month
Baseline
% Patient Care Employees rating as "Moderate/High"
Medical Home Control Clinics
Emotional Exhaustion
Depersonalization
Lack of Personal Accomplishment
**
Utilization & costs in medical home
Year 1: • 29% fewer ER visits • 11% fewer preventable hospitalizations • 6% fewer but longer in-person visits • No significant difference in total costs between medical home
and control clinics
Year 2: • Significant utilization changes persisted • Overall patient care costs lower at medical home (~$10 PMPM)
Lessons learned from Group Health’s patient-centered medical home pilot
Patient-centered care saves costs by lowering inappropriate use of emergency care and avoiding preventable hospitalizations.
Investment can achieve relatively rapid returns across a range of key outcomes, even in an already integrated system.
The evaluation provides some of the first empirical evidence of the benefits of the medical home.
The evaluation gave leadership the confidence to invest $40M in redesign of primary care, spreading the medical home to all 26 of its medical centers.
The evaluation served as a model for our evolving learning health care system.
Group Health’s concept of a learning health care system (LHCS)
Unwarranted variations in surgical care are pervasive in the U.S.
Variation within the Group Health system
More LHCS projects have followed Example: Shared decision making
In 2009, Group Health launched a system-wide shared decision making initiative
12 video-based decision aids in six specialty services:
• Orthopedic: hip and knee osteoarthritis
• Cardiac: coronary heart disease
• Urology: benign prostatic hyperplasia and prostate cancer
• Women’s health: uterine fibroids and abnormal uterine bleeding
• Breast cancer programs: early-stage breast cancer, breast reconstruction, and ductal carcinoma in situ
• Back care programs: low back pain from spinal stenosis and herniated disc
SDM is not new to Group Health, but translating findings is
Group Health published studies on the value of SDM for BPH and low back pain the mid-1990s. Results: High patient satisfaction, lower cost.
But we lacked mechanisms to move such findings into practice.
Wagner EH et al, Med Care 1995;33(8):765-70
Health Affairs: September 2012
Large scale implementation of patient decision aids is feasible
Use of decision aids for SDM appears to be one way to achieve the “triple aim” in health care
Improves patient satisfaction (& knowledge)
Appears to lower rates of elective surgery
Reduces costs or is at least cost-neutral
Is generally well-accepted by providers
Offers potential for greater liability protection
SDM conclusions to date
LHCS example: Addressing risks of chronic opioid therapy
Group Health Research Institute: Higher opioid dose linked to overdose risk in chronic pain patients (Annals of Internal Medicine, 2010) Washington State guideline: Safe opioid prescribing requires clinical evaluation, treatment agreements, periodic monitoring, urine drug screening, and medical records treatment documentation Federal Action Plan: Epidemic—Responding to America’s Prescription Drug Abuse Crisis (Office of National Drug Control Policy, April 2011)
An epidemic of prescription opioid abuse
LHCS example: Addressing risks of chronic opioid therapy
Group Health launches a comprehensive opioid prescribing safety initiative in 2010.
• Objectives: standardized practices, clarification of treatment goals and expectations, fewer cases of abuse, misuse, and overdose
• Standardized care plans: one responsible prescribing physician, refill planning and monitoring, urine drug screening for high-risk patients, referral guidelines
• Training: Web-based CME on how to implement the standardized care plans, funded by the Group Health Foundation
The initiative produced stunning results that outpaced the federal call to action (April 2011)….
LHCS example: Addressing risks of chronic opioid therapy
Note: Chronic opioid therapy defined as having filled at least 5 prescriptions in the past 90 days or
taking opioids for at least 90 days in a pattern or quantity that indicates daily or near-daily use.
By May 2011, 85% of Group Health chronic opioid therapy patients had documented care plans.
LHCS example: Addressing risks of chronic opioid therapy
Today, COT care plans at Group Health are nearly universal.
Partnership for Innovation: An opportunity to pilot clinical staff’s ideas
Group Health Research Institute
• Non-proprietary, public interest science
• Focus on practical research
Group Health Partnership for
Innovation • Ideas come from Group Health staff • Funded by Group Health Foundation • Group Health Research Institute
helps design & evaluate
Group Health care-delivery system
• 1,200 physicians • Patient-centered care • Aligned incentives to innovate for better care
Partnership for Innovation
Grantee selection criteria
• Will it promote better care at a lower cost?
• Is it a new process, product, or service?
• Is it an incremental change?
• Is it patient centered?
• Is it feasible?
• Does leadership support the work?
Some examples…
Pediatric intranasal flu vaccine
Total funding: $75,532
Innovation Provide painless flu-vaccine option for children
Potential benefits
• Increase flu vaccination rates • Increased patient/family satisfaction
Results • Parents perceived intranasal vaccine as risky • Uptake was lower than expected • Intranasal vaccine program dropped
Outpatient orthopedic ultrasound
Total funding: $34,897
Innovation Diagnosing shoulder injuries in outpatient setting with portable ultrasound device
Potential Benefits • Less use of high-end imaging • Higher patient satisfaction Results • Demonstrated reduction in MRI usage • 200 percent return on investment • Will expand system-wide
Learning health care systems can address the BIG questions for U.S. health care
What’s the best use of limited resources?
What works? What doesn't?
How can we cut out waste, inefficiencies, errors?
How can we leverage the strengths of integrated care systems?
How can we address the problems of an aging population?
How can we address growing burdens of chronic illness?
How can we contain costs so we can afford to care for the expanded number of people who will soon have coverage?
Research Collaboration & Health Care Systems
Andy Nelson, MPH, Executive Director
Jane Duncan, MPH, Research Network Manager
HealthPartners Institute for Education and Research
HealthPartners
Founded in 1957, HealthPartners is the largest consumer-governed nonprofit health care
organization in the nation • Serving more than 1.4 million medical and dental health plan members
nationwide • 1 million patients served at HealthPartners & Park Nicollet facilities
– Five regional hospitals – 44 primary care clinics – 18 urgent care locations – 20 dental clinics – Numerous specialty practices throughout Minnesota & western Wisconsin
HealthPartners Institute for Education and Research
• Research Foundation & Education merged in 2012 – 35 professional educators & certified instructors – 45 investigators and clinician researchers
• Education Programs include: – Undergraduate and graduate clinical education – Clinical simulation – Continuing education – Learning collaboratives
• Research Programs include:
- Chronic disease - Cancer - Mental Health - Ethics - Health Economics
- Clinical Research - Oral Health/Dentistry - Child & Maternal Health - Alzheimer’s Disease/Neurology - Critical Care
HMO Research Network
The HMO Research Network is a consortium of 19 health care delivery organizations with both defined patient populations
and formal, recognized research capabilities
• Mission: To improve individual and population health through research that connects the resources and capabilities of learning health care systems
• Vision: The HMO Research Network is the nation’s preeminent source of population-based research that measurably improves health and health care
• Values: Scientific excellence; innovation and creativity; actionable research findings; collaboration and teamwork; transparency; efficiency
HMO Research Network
Research Networks within the HMORN
Major HMORN Research Networks by Subject Interest Area: • Cancer Research Network (CRN) 1999-present, NCI, $80M, >
75 studies, 14 HMORN sites PI = Larry Kushi, KP N Calif. • Cardiovascular Research Network (CVRN) 2007-present,
NHLBI, $30M, 15 HMORN sites PI = Alan Go, KP N Calif. • Developing Evidence to Improve Decisions about
Effectiveness (DEcIDE 1 and 2) 2005-present, AHRQ, $17M, > 13 task orders, 14 HMORN sites DEcIDE 2 PIs = Richard Platt, Harvard Pilgrim HC and Alan Go, KP N Calif.
Research Networks within the HMORN
Major HMORN Research Networks by Subject Interest Area: • HMORN Community Provider Network Partnership (ACTION
II Network) 2010-present, AHRQ, 14 HMORN sites plus UCSF and SHIRE PI = Julie Schmittdiel, KP N Calif.
• Mental Health Research Network (MHRN) Funded 2010, NIMH, 10 HMORN sites PI = Greg Simon, GHRI
• Surveillance PREvention and ManagEment of Diabetes Mellitus (SUPREME – DM) 2010-present, AHRQ, 12 HMORN sites PI= John Steiner, KP CO
Midwest Research Network
Regional Network launched in 2011 • Mission: To provide a space for the health care community to
collaborate in the development, implementation, and application of research that improves the health outcomes, experience, and affordability of health care for all of the people in our region.
• Members: Research organizations, Providers, Payers, Government Agencies, University of MN CTSI, Quality Improvement Organizations
• Working together in areas of Informatics, Mental Health, Clinical Decision Support, and Consumer Engagement
Example of Successful Collaboration Mental Health
Mental Health Research Network (MHRN) • National network funded by NIMH in 2010 • 11 research centers partner with health systems that finance
and provide care for a diverse population of over 10 million people in 12 states.
• Wide range of mental health conditions and treatments, including those affecting children, adults, and seniors.
• Closely engaged with health system partners and external patient, provider and quality improvement groups.
• Reach extended to Regional level: Mental Health Interest Group within the Midwest Research Network led by MHRN Investigator
Successful Collaborative Projects Education and Research
The CV Wizard - Clinical Decision Support to Improve Chronic Disease Care
• Primary goal to reduce cardiovascular risk in patients at moderate to high risk for heart attack or stroke.
• Personalized CDS algorithms integrate multiple data sources and identify patient-specific, data-driven treatment options.
• Decision support tool relays potential reversible risk. • Physician and Patient interface to prioritize. • Developed by primary care physicians, researchers, and
education professionals. • Implemented in HealthPartners Medical Group.
Successful Collaborative Projects Education and Research
SimCare - Simulated Diabetes Learning for Health Care Providers
• Web-based EMR-like interactive program used to educate Residents and Clinicians in Diabetes care.
• Curriculum is embedded within 18 explicit virtual cases with type 1 or type 2 diabetes.
• Simulation model operates “behind the curtain” to calculate physiologic outcomes of provider actions.
• Library of tailored learning feedback and messages are deployed to critique and guide provider actions.
• Developed over 12 years by medical experts, researchers, and education professionals.
Principles of Successful Collaboration
Relationships based on Goodwill • Alignment with each organization’s Mission Statement and Strategy. • Focused on a larger longer-term research agenda as well as individual projects. • Committed to a shared, balanced, transparent and supportive governance and
leadership structure. • All members of the collaboration are involved and represented in the full
continuum of research activities. (governance, resources, development, publications)
• Clear policies exist that address the ongoing operations and governance of the collaboration.
• Opportunities and benefits of participating in the relationship are apparent and outweigh the costs: Expertise, Financial, Partnership Opportunities.
• Stewardship of members, patients and providers are central to any and all data sharing arrangements.
• Employs efficient and proven administrative processes and templates that are synergistic with other partnerships.
Applying the Learning Health System Model
March 21, 2013
Group Health’s concept of a learning health care system (LHCS)
• You are the CEO of an academic medical center and you arrive to work on a Tuesday in February 2010 to a stack of phone messages and an inbox full of emails from Board members, community leaders, and friends…..
Housewide Central Line Associated Bloodstream Infections by Month
1/06 - 10/07
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r 100
0 de
vice
day
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70% Reduction since 2006 Central Line Infection Rate, ICU's
8.92
3.964.52
2.73
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 (10 mo)
Year
infe
ctio
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er 1
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ine
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Rate
Group Health’s concept of a learning health care system (LHCS)
Small Group Exercise
• Choose a team leader, timekeeper at your table
• Read the Exercise Scenario on your table
• Discuss your experiences and produce a list of three possible interventions to achieve learning health system in each of two domains
FY 06-12 CLABSI Infections/1000 cath. days MMC wide
Target <1/1000
• Structural – 1. Vascular Access Team – 2. Vascular Access Center – 3. Unit-based Physician/Nurse Quality Dyads
• Behavioral – 4. 100% compliance with all bundle elements – 5. Limit blood draws and who accesses lines – 6. Line maintenance and documentation
Central Line Dashboard
Maine Medical Center’s Approach
Internal/External Review
Phases I & II Phase I • Conducted over 80 internal interviews
across clinical and non-clinical areas – Included MaineHealth and
volunteers – Included employees at all levels and
functions Phase II • Visited 2 external healthcare
organizations: Virginia Mason & UMASS Amherst
• Visited 1 external non-healthcare organization: Bath Iron Works
Phases III & IV Phase III • Held 7 two-hour team workshops to
analyze findings, determine implications, identify best practices and develop recommended strategies and tactics – Used SWOT and STAR model
frameworks Phase IV • Transformed results of workshops into
40 page deliverable • Reviewed deliverable with key
stakeholders
Recommended Strategies
• Design – Implement standardized process improvement
methods and rigorous standardized reporting.
Recommended Strategies • Implement
– Establish a standardized management system by which leadership models improvement behaviors.
• Senior leaders model improvement behaviors characterized by leading local performance huddles and spending more time at the frontline engaging all in meeting AIP goals.
• Senior leaders develop competence in process improvement methods and actively sponsor improvement projects.
– Establish Dyad Quality Officers in each service line in order to provide standardized leadership of performance improvement.
– Expand incentive-based compensation program to reward achievement of team-based goals for all employees.
Recommended Strategies
• Evaluate – Move the business intelligence/analytic function and the
process improvement expertise function into a single group to the COO office for better alignment to the service line structure.
– Develop a high-performing, interdisciplinary data analytics team that adheres to industry best practice standards.
• Centralize data analytics resources into single group by reporting relationship
– [Formal dedicated PhD support from Center for Outcomes Research and Evaluation (CORE) to the medical center quality improvement group.]
Discussion