learning health care systems

Engines of Success for U.S. Health Reform?

Eric B. Larson, MD, MPHVice President for Research, Group HealthExecutive Director, Group Health Research Institute

Learning Health Care Systems

Grand Rounds I Beth Israel Deaconess Medical Center I January 24, 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

Berwick & Hackbarth on the problem: Eliminate systemic waste (JAMA 2012)

Total U.S. health care system waste = $11 trillion over nine years

“The savings potentially achievable from systemic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage.”

A matter of professional ethics

To make a difference, we must address all categories at once:

• Overtreatment

• Failures to coordinate care

• Failures in care delivery

• Excess administrative costs

• Excessive health care prices

• Fraud and abuse

Addressing waste is a matter of professional ethics.

Waste must be addressed by professionals from within the system.

Estimated annual waste by category

Single-year (2011) estimates based on a review of the waste literature, after resolving overlapping areas:

6

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.”

The challenges. The opportunity.

In learning health care systems, traditional principles of research can be used in more practical ways so that:

• Decisions can be made more quickly.

• Better information is available for clinical decision making, for managing health care delivery.

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.

One example: Group Health CooperativeFounded in 1947 “To Serve the Greatest Number”

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

Today at Group Health Research Institute

Non-proprietary, public interest

About 300 employees working on more than 250 concurrent studies

39 scientific investigators, including MDs, epidemiologists, biostatisticians, health services researchers, psychologists

33 affiliate investigators (mostly UW, Group Health medical staff)

More than 300 publications in peer-reviewed journals each year

Grant dollars in 2012: $46.3 million

Improved health & health care through research, innovation

& dissemination

Primary areas of research focus

Health Systems Organization &

Finance

Preventive Care &Health Promotion

Cancer Prevention & Control

Chronic Illness Care

Immunization

Biostatistics

Women’s Health

Mental Health and Behavioral Medicine

Research is in Group Health’s DNA

1947: Group Health’s original mission statement: “Contribute to medical research”

1950s-60s: University-based researchers mine Group Health data beginning in 1956 with the Seattle Longitudinal Study on Aging

1970s: Group Health’s own research on its preventive care services began

1983: Group Health Research Institute (GHRI) founded with Ed Wagner, MD, MPH, as director

Research is in Group Health’s DNA

1980s:

• NCI funds phone-based tobacco cessation research, leading to changes in coverage, successful quit lines nationwide

• Bike helmet studies show link to reduced head injuries, leading to bike helmet laws and wide-spread use

1990s:

• Chlamydia screening proven effective against PID; CDC recommends Chlamydia screening

• Collaborative care proven effective for depression

Early 2000s:

• Alternative care can help back pain

• Improved diabetes care reduces cost

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

• 1988: 1 of 5 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):835-43Larson 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

** p<0.01

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.

The Dartmouth Atlas Project has found widespread geographical variation nationwide in the use of elective surgical procedures.

Patients in Wenatchee, WA are three times more likely to have their arthritic knees replaced than are similar patients in Honolulu.

Men in Bellevue, WA are much less likely than those in Thousand Oaks, CA to undergo surgery for benign prostate disease.

This variation reflects physician training and preference—not what patients want or need.

Variation within the Group Health system

More LHCS projects have followed Example: Shared decision making

2007: Washington State passes nation’s first law endorsing shared decision making (SDM)

SDM provides shelter from liability

State mandates demonstration projects, leading SDM research at Group Health.

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

Preliminary findings in women’s health and urology

Impact on surgery useImpact on surgery use

Impact on health care costs

Impact on health care costs

UntreatedBPH

Unpublished findings

ProstateCancer

AUB/Fibroids

TreatedBPH

LHCS example: Reducing harms from advanced medical imaging

Group Health study shows wide variation in radiation exposure from computed tomography (CT) scans and increased use over time.

Smith-Bindman R et al, JAMA 2012;307(22):2400-9

LHCS example: Reducing harms from advanced medical imaging

Estimated that CT-induced cancers could be reduced by 40% if the highest 25% of radiation doses from pediatric CT could be lowered to the median dose.

Based on these results, Group Health began developing ways to lower radiation exposure from medical imaging.

Researchers and the radiology service collaborated to provide CT technologists with feedback reports, training on CT doses.

The technologists are eager for more education and want to engage radiologists in discussions about developing dose monitoring protocols.

Researchers will evaluate whether dose-feedback reports and dose-reduction education reduce radiation exposure for Group Health patients.

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


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)….

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.


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?

What we have learned in developing a LHCS at Group Health

We can learn more quickly, produce more timely results.

Research can align with the care-delivery system’s business goals.

We always strive for projects that are:

• Generalizable

• Public-domain

• Leading to nationally relevant discoveries and solutions

Funding these projects can be challenging, but not impossible.

What does the future hold for LHCS?

New sources of support:

Patient Centered Outcomes Research Institute

• Founded in 2010 under the Affordable Care Act

• Nonprofit, nonfederal, independent

• Patient and stakeholder input influences all phases

• Patients and stakeholders are reviewers

• Budget: $3 billion for 2012-2019


New sources of support:

Health Care Systems Collaboratory

• Established by NIH Director Francis Collins, MD, PhD, through the Common Fund

• Engaging health systems in large clinical studies

• Coordinating Center at Duke University funded in 2012

• $11.3M for first year

• Includes HMO Research Network (19 integrated health plans)

• Recently funded seven “pragmatic trials” to develop and spread best practices—includes studies of suicide prevention, colorectal cancer screening, and care for low back pain


New opportunities through large, multi-site studies:

Example: The Mini-Sentinel

• Funded by the FDA

• Active, extensive surveillance system to monitor the safety of regulated medical products

• Gathers data from 29 health care organizations nationwide

Conclusion

The potential is rich.

Can Victor Fuchs’ assessment be right? Will change only come through an unraveling of the current system?

Or can we make our learning health care systems the engines of success for U.S. health reform?

Let’s take this as a matter of professional ethics, exercising professional obligations to our patients.

Let’s drive the change, achieving de Tocqueville’s prediction of inevitable and positive change.

Questions?

learning health care systems

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