[This Transcript is Unedited]
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
Subcommittee on Populations / Workgroup on Quality
PATIENT-CENTERED MEDICAL HOME HEARING
MAY 20, 2008
Renaissance Washington Hotel
999 9th Street, NW
Washington, D.C. 20001
CASET Associates, Ltd.
Fairfax, Virginia 22030
TABLE OF CONTENTS
- Measuring the Performance of the PCMH
- Barbara Starfield, M.D., M.P.H.
- Economic Models — Measuring Sustainability — Assess
Its Value; Determine What to Pay For
- Howard Underwood
- Reva Winkler
- Karen Boudreau
- Measuring the Performance of the PCMH (Continued)
- James M. Walker
- Use of Data Sets to Assess the Existence and Performance of PCMH
- Doris Lefkowitz
- Stephen Blumberg
- Catharine Burt
- HIT and PCMH Measures, Data and Standards
- Christopher Nohrden
- David Hunt
- Michael Klinkman
- HIT System Support of PCMH
- David C. Kibbe
- David Hunt
- Terry McGeeney
- Jim Walker
- Public Testimony
- Action Items/Next Steps
- Justine Carr, M.D.
P R O C E E D I N G S (9:06 a.m.)
DR. STEINWACHS: Good morning. I am Donald Steinwachs, the Chair of the
Populations Subcommittee of the National Committee on Vital and Health
Statistics. And I, along with Justine Carr, who chairs the Quality and Data
Subcommittee, welcome you to joint hearings on the medical home.
This is our second day, and first day, or first half day, we spent learning
a lot about how people are measuring whether or not a medical home exists and
expectations and a vision for what the medical home hopefully will do to
reinvigorate primary care and transform the American healthcare system.
We also will share experiences in implementing the medical home in North
Carolina — Harry pointed out to me that was a very important state — and also
in family practice and some of the plans and thinking that’s going into the CMS
demonstration on the medical home.
Today, we’re really looking forward to advancing that agenda, and we have a
series of outstanding speakers to start out the morning on the measurement, in
a more comprehensive way, of the concept of medical home and primary care.
And so it’s a great pleasure to have everyone with us.
Before starting the program, would like to do introductions around the
table and around the room.
And so I am Don Steinwachs. I’m at Johns Hopkins University, and I’m a
member of the committee.
DR. CARR: Justine Carr, Beth Israel Deaconess Medical Center and member of
DR. TANG: Paul Tang, Palo Alto Medical Foundation. Member of the committee
DR. QUINN: I’m Matt Quinn with Agency for Healthcare Research and Quality
and working with NCVHS.
MR. REYNOLDS: Harry Reynolds, Blue Cross and Blue Shield of North Carolina.
Member of the committee.
MR. LAND: Garland Land with National Association for Public Health
Statistics and Information Systems. Member of the committee.
DR. FRANCIS: Leslie Francis, Philosophy and Law, University of Utah. Member
of the committee.
DR. GREEN: Larry Green, University of Colorado, member of the committee.
DR. KLINKMAN: Mike Klinkman, family physician from the University of
Michigan and a guest of the committee.
DR. BETHELL: Christina Bethell from Oregon Health and Science University
and a guest of the committee.
DR. BLUMBERG: Stephen Blumberg from the National Center for Health
Statistics and a guest.
DR. WINKLER: I’m Reva Winkler, National Quality Forum. I’m also a guest.
DR. STARFIELD: Barbara Starfield, Johns Hopkins University. I want to say
member of the committee, which I said for eight years —
DR. STEINWACHS: For so many years.
DR. UNDERWOOD: I’m Howard Underwood from the Deloitte Center for Health
Solutions. Guest of the committee.
DR. WALKER: Jim Walker, Geisinger Health Systems. Guest of the committee.
DR. BOUDREAU: Good morning. I’m Karen Boudreau. I’m from Blue Cross Blue
Shield of Massachusetts, and I’m also a family physician, and I’m a guest of
DR. MC GEENEY: Terry McGeeney from the American Academy of Family
Physicians and guest of the committee.
MS. KANAAN: I’m Susan Kanaan, writer for the committee.
MS. JACKSON: Debbie Jackson, National Center for Health Statistics, CDC,
MS. GREENBERG: Good morning. I’m Marjorie Greenberg, National Center for
Health Statistics, CDC, and Executive Secretary to the committee.
I just want to welcome Barbara and say that she is living proof of what we
always tell retiring members, that you never actually retire from this
MS. VIOLA: Allison Viola, American Health Information Management
MS. CAPP: Mary Capp, Centers for Medicare and Medicaid Services.
MS. ETTS: Rebecca Etts(ph), Robert Wood Johnson Medical School.
MS. TRINITY: Tricia Trinity(ph), Agency for Healthcare Research and
MS. CROSS: Dorie Cross(ph), Agency for Healthcare Research and Quality.
MS. GRAYS: Aaron Grays(ph), Agency for Healthcare Research and Quality.
MR. HALL: Robert Hall with the American Academy of Pediatrics.
MS. Bornstein: Claire Bornstein(ph) with the American Academy of
MR. MEYERS: David Meyers(ph) with the Agency for Healthcare Research and
MS. JONES: Catharine Jones. National Center for Health Statistics, CDC.
MS. JAMISON: Missy Jamison, National Center for Health Statistics.
MS. GORI: Laura Gori(ph), Blue Cross Blue Shield of North Carolina.
MS. WILLIAMS: Kim Williams, National Patient Advocate Foundation.
DR. STEINWACHS: Thank you very much.
As I think you know, these proceedings are being broadcast on the web and
are being recorded, because federal advisory committees do meet in the open,
and so that there may be people listening in and joining us in that way.
DR. STEINWACHS: The leadoff presentation, we’ve asked Dr. Starfield if she
would share with us what has been the culmination, in my mind, of years of
outstanding work on both the conceptualization of primary care and the
measurement of primary care. And as we heard yesterday in the vision that the
medical home is seen by most as an effort to reinvigorate and transform
American healthcare and strengthen primary care.
Dr. Starfield is university professor at Johns Hopkins University and is
active around the world. Anytime I see Barbara, I ask her where she’s been
recently and it’s another place in the world that’s trying to learn from her
about primary care. So thank goodness you’re here to teach us about primary
DR. STARFIELD: Thank you, John. Thanks.
I didn’t ever think I’d talk about primary care at a national level in the
United States ever again, and in the last 10 years, I’ve been mostly abroad
talking about it.
Last week, I was in Geneva — actually, the meeting was in Montreux — and
there’s going to be a World Health report on primary care, which is real
exciting. There’s a draft out now, and a few of us went — were invited to come
and review it, and that was invigorating.
But I can’t say I’m invigorated to be back here talking about primary care,
except this spring has been pretty — it’s been warming up. Not the global
warming, but something’s happening in the U.S.
DR. STEINWACHS: Primary-care warming.
DR. STARFIELD: So, you know, it’s opportunity, danger plus opportunity —
It’s a crisis, now, I think, in the U.S., but there is an opportunity, but
there still are some dangers.
So I want to talk about measurement, because that’s really what I was asked
to talk about. I can’t talk about measurement without talking about concept. So
we talk about concept first, and then just talk about maybe some things that
you need to be concerned about with this medical-home movement.
Okay. Primary care works, because it has definable functions that provide
the policy context for primary care.
And I’m not going to go through all the evidence that primary care works. I
have it at the end of the slide, in case we — somehow a speaker doesn’t show
up and you need to fill more time, but we won’t go through that.
Primary care works because it has defined functions that include structural
and process features of health services that are known to improve outcomes of
And I’m going back to Donabedian. Who in this room has not heard of
Donabedian? Who has heard of Donabedian?
Yes, well, that’s great. You’re a special bunch. Most people have not heard
A framework based on structure, process and outcome is helpful in
describing and measuring the components of health services systems of which
primary care is a part.
And this is it. Donabedian said structure, process and outcome. I made the
terms a little more modern — capacity, performance and health status.
But what Donabedian didn’t do — He didn’t have to. He did so much else,
but he didn’t really define what was in structure, process and outcome, at
least not very clearly in terms that could be measured, but that’s what we’ve
done in this diagram.
I actually published this in the New England Journal in 1974.
And in capacity are things like the personnel that are there, the
facilities and equipment, the range of services — You have this in front of
you. So I don’t have to go through it again.
And the process of care has two parts, that which we, as providers, offer
and that which the population and the patients do.
So there’s two parts to process of care, the provision of care and the
receipt of care. And in between the two is the patient-physician — the
And then we have outcome, and there are lots of ways of measuring outcome.
This just happens to be mine, but it’s not what we’re going to talk about
And this with the contribution of the cultural and behavioral
characteristics, the social, political, economic and physical environments and
biological endowment constitute the health services system.
And this can be viewed on the population level, on the facility level or on
the practitioner-patient level. It’s equally applicable.
Now, primary care has four features, all have to present together — first
contact, longitudinality, comprehensiveness and coordination. And each of these
four features is measured by a capacity function, one of those structural
elements, plus a behavioral element. So the facility or the system has to have
a structural element that makes the performance possible.
So for first contact, you have to be accessible, the system has to be
accessible, and it has to be used by people the first time they have a new
need. The longitudinal person-focused over care time has to be a relationship.
The structural feature is the relationship between the facility and its
population or the practitioner and his or her patients and has to be used by
people over time regardless of the type of problem, a person-focused character,
not disease-focused character of health systems and services.
Comprehensiveness means that the structure has to include a broad range of
services to meet the all but rare needs of the population. But, in fact, the
behavioral characteristic is you have to recognize situations where services
are needed. And coordination is a mechanism for achieving continuity. It’s a
structural mechanism coordination. And then the behavioral component of it is
recognition of problems that require follow up.
Okay. So here’s the health services system structure, process and outcome.
And I’ve put in blue those structural features and those process features which
together define primary care. And here it is again. That’s the same thing. It
shows the essential features in the middle, first contact, longitudinality,
comprehensiveness coordination and the elements of structure and the elements
of performance that have to be achieved before you have good primary care.
Now, there is no formal quality assessment approach that includes the
critical feature of problem-recognition — and that’s part of two of the unique
features of primary care is recognizing problems in the population and in
patients — despite the evidence that patients are more likely to improve when
they and their practitioners agree on what their problem is.
There have been studies that show that when — Practitioners and patients
are much likely to get better on follow up if they and they their practitioners
have agreed on what their problem was. And that’s where they’re judged by the
practitioner or judged by the patient that is the improvement.
I don’t know of any quality assessment system that looks at whether or not
the system, the practitioner recognize what the patient’s problem was. I’d love
to be corrected.
And there’s no formal quality assessment approach that includes range of
services, despite the evidence that a broader range of services provided in
primary care is characteristic of stronger primary health systems.
I don’t know of any caps whatever, any quality assurance system that looks
at the range of services that are provided by primary care, or specialty care,
for that matter. Nobody really has thought about what services should be
provided, at least not in this country. Elsewhere, yes, but not here.
And I think that’s probably at least because a lot of the instruments we
use now to look at quality of care were invented before we thought it was
important to distinguish primary care from secondary and tertiary care. So none
of those instruments are good for primary care.
Now, there are criteria for comprehensiveness in U.S. studies. They are
things like universal provision of extensive and uniform benefits for children,
the elderly, women and other adults; routine OB care; mental health needs;
minor surgery and generic preventive care. I don’t mean disease-oriented
preventive care. I mean generic preventive care, person oriented, not disease
In European studies, they’ve done a lot of work with comprehensiveness
based on specific diseases. But they also have looked at — have used technical
procedures, like wart removal, IUD insertion, removal of corneal rust spots.
Most of you are thinking, that’s not primary care, but, in fact, in most of
the world, that is primary care, all these kind of things, joint injections,
taking Pap smears, et cetera. Primary-care-oriented countries have greater
comprehensiveness, greater range of services available and provided.
Now, comprehensiveness and primary care, the draft instruments that are
being developed now to look at the medical home, do not have any evaluation of
comprehensiveness of care, at least not as of a month ago.
So we did a little survey, both in this country as well as — at least one
person from every WHO region, and these are the characteristics that everyone
— there are 14 respondents, people that I knew would know that have to be in
primary care. Wart removal, suturing lacerations, removal of cysts. You have
the list. I don’t have to go through it. I ask each of you to think in your own
mind does your primary-care practitioner do these things for you?
As primary-care oriented as I am, I once had pain in my ankle. I had to get
to a meeting. So I had to get care really quick and I went to my primary-care
physician, who’s an internist trained at the Johns Hopkins Hospital where we
have no primary-care training. And I said to her — I went to her first. I
didn’t try to make an appointment with the orthopedist, and I said,
“Laura, I need a referral.” She said, “No, you don’t.” And
she took out a needle and syringe and tapped my joint.
And I said, “Well, you were trained at Hopkins. I know you didn’t
learn that there.” And she said, “No, I discovered I had to teach
myself.” Limitations of current assessments of primary care.
There’s no assessment of the critical feature of problem recognition. None
that I know of. No assessment of comprehensiveness of either primary care at
the system level or primary care at the clinical level.
An over emphasis on quality of care for specific diseases, little
assessment of person-focused measures. And you’re going to miss all the side
effects if you’re focusing on diseases.
Under development of the concept and measurement of coordination. I don’t
recall whether I have further — the other reason why it’s important to look at
person-focused measures, and that’s because of comorbidity, which is increasing
rapidly over time. We don’t have time to go into that.
Now, there have been enhancements to primary care, most recently proposed
in the context of the medical home, and they include health information
systems, primary care and system wide.
And I remind everybody around this table that there’s no evidence that I
know of that electronic health records — even though I served on this
committee where we advocated the electronic health record, and I think they’re
great and I think we ought to move towards it, but there’s still no evidence
that they contribute to the four functions of primary care. Okay. So can’t
define the medical home by the presence of an electronic health record.
Analysis of variations of care with variations in use of secondary care,
with variations in type of payment and with a focus on patients versus a focus
And in the UK, they do have some P4P efforts that are person focused. As
far as I know, we don’t have many, if any, in this country.
Subspecialization in primary care has been sort of on the agenda in the UK
for half a dozen years, and we’ve recently done a literature review on that.
There’s no evidence that subspecialization enhances either the
comprehensiveness or any other features of primary care, and, in fact, the more
training you have in a particular aspect of primary care, the more you refer,
not the less. We can discuss why that’s the case.
Patient-centered primary care is very poorly conceptualized. I’ve been
collecting definitions of patient-centered or person-centered and there’s no
agreement on what this term means.
The chronic-care model, which is self-management support, delivery system
design, decision support, clinical and information systems. And while there’s
some evidence that some aspects of the chronic-care model, particularly the
aspect that is responsible for follow up, are useful, there is no evidence that
the model itself contributes to the primary-care functions.
So all of these, all of these proposed, mostly in the context of the
medical home, all require evaluation in the context of whether they contribute
to the primary-care functions.
Primary care and the medical home, are they the same? The defense of the
medical home has been on the basis of the evidence on the benefits of primary
care. Right. So the medical home concept has been defended on the grounds that
it’s primary care.
Primary care is a 90-year-old concept. It was first mentioned in the UK in
1919 in the Lord Dawson report. And he didn’t actually speak of primary care.
He spoke of primary-care centers, but he described it in a way that we would
recognize as primary care. So it’s 90 years old.
It has a very precise definition, now pretty much accepted, at least in
countries other than the United States, and it has a standardized measurement.
The medical home is a 40-year-old concept. It was invented by the American
Academy of Pediatrics, but it was invented really to talk about children with
special healthcare needs, and it was recognized that they didn’t have a medical
home. They were being shunted around from place to place. So that’s where it
came from, people with special needs, but it was about in the late 1960s. It
has an imprecise definition and unstandardized measurement.
How do we know if ways of delivering services are essentially the same,
fundamentally different, complementary or supplementary? That is, how do we
know whether the medical home is primary care? Well, at the very least, we need
to know the essential principles and functions.
The joint principles of the patient-centered medical home — this comes
from a document from March 2007 — is personal physician: Ongoing relationship
for first contact, continuous, comprehensive care. So far, so good. They use at
least the right words.
Physician-directed medical practice. Whole person oriented. Coordination
and/or integrated care. Quality and safety. Enhanced access and added-value
payment. You can recognize some of them as pursuant to primary care.
Physician-practice connections, the PPC-PCMH standards.
Now, as of a month ago, about 230 items have to be recorded. Most of these
assess structural elements of practice. Very few assess behavioral and
performance aspects of practice. Most are simply good medical care, not
specifically primary care.
There’s little or no evidence of the usefulness of many, if not most, of
these elements that are proposed for measurement.
And there are no elements addressing interpersonal interactions,
recognition of patient/population problems, follow up to assess improvement or
comprehensiveness of care, either the appropriate range of services or
comprehensiveness of care provided.
Now, I sort of understand why this is. All these take a little work to do.
You can’t get them right off a record. But, still, most of these are very
pursuant to what’s important in primary care.
And this is the distribution of items on the last instrument that I saw.
This was in March. As I said, there’s over 200 items. There are 17 having to do
with access and communication, 57 having to do with tracking and registry, 54
having to do with care management, nine having to do with patient self
management, 19 having to do with electronic prescribing, 14 having to do with
test tracking, four having to do with referral tracking, 32 having to do with
performance tracking of the kind you’re very familiar with and 14 having to do
with advanced electronic communication.
I don’t recognize much in here that’s pursuant essential primary-care
functions. At the very least, any instrument to assess the quality of primary
care or the medical home or whatever we call it, ought to include assessment of
comprehensiveness and a coding system that captures patients’ problems.
Okay. We need to know the breadth of services offered and delivered, and we
need to be able to capture what patients’ problems are. And we will never do it
with the coding systems we use now.
I don’t know where the ICPC stands. I know we talked a lot about it when we
were on the committee, but I don’t know where it is now in terms of the minimum
data requirements for any kind of health services.
Now, I won’t talk about a special tool unless you want to hear about it.
You’ve got it all in your packet. And I think I’m going to stop here and stay
within my time, if that’s okay with you.
DR. STEINWACHS: Very nice. Thank you, Barbara.
Let’s open it up to questions and comments.
Barbara, why don’t you, at least for me, and I think for others of the
committee, give us a brief walkthrough on the primary-care assessment tool,
because we were — yesterday went through the PPC and some of the others just
to get it. We didn’t go in detail, but went through the basic concepts and
DR. STARFIELD: Okay. The PCAT, the Primary Care Assessment Tool, has been
around for about 10 years. We developed it at Hopkins, and we originally
developed it for use with children, but it’s now being expanded for use in
adults, and we now have added a systems instrument.
And, now, all of these versions are parallel. We have an adult consumer, a
long and a short version, a child consumer, a long and a short form, a facility
version, a long and a short form, and a provider version, a long and a short
form, and they’re all both structure and process on them.
And we have, now, the primary healthcare assessment tool, because abroad,
they talk more about primary health care. We talk about primary care, but they
talk about primary healthcare, and they’re talking, really, about the systems
in addition to the clinical practice.
So we have a primary healthcare tool that’s a systems assessment that we
ask of policymakers and managements, but they get at both the structural and
the process elements.
They’ve used this extensively in Catalonia. They use it in their Catalan
health survey. They tested it. They validated it in Spanish and in Catalan.
They use this many places in Brazil. They’re translating it for use in Malta
and in China. They’re using it in Thailand. But as far as I know, we’re not
using it in the U.S.
Yes, it’s in English, Spanish, Catalan, Portuguese, French — they’re using
it in Quebec — Korean and in progress, the Mandarin and the Maltese. And if
the U.S. is serious in pursing the World Health Organization goal of primary
healthcare — and it may be 2009. We may not get it ready in 2008 — it must
come to grips with defining and assessing health services according to
evidence-based functions associated with primary-care systems and practices,
and that’s been lacking on a system-wide basis.
Is that enough?
DR. STEINWACHS: Sounds good.
MR. REYNOLDS: Yes, thank you. Could you tell me a little more about the
coding system that you’re talking about that captures patient problems —
DR. STARFIELD: The ICPC, International Classification of Primary Care. Is
that what you mean? That’s what you’re asking about.
MR. REYNOLDS: I’m not a physician, so —
DR. STARFIELD: Yes. That was developed, oh, maybe – I don’t know – 20 years
ago? That about right, Marjorie? Something like that — by WONCA. And, Larry,
you know a lot about it, right? The World Organization of National Colleges,
Academies. It’s the family practitioners of the world.
And they said, “The ICD isn’t useful for us.” OK? “We deal
with problems in family medicine and primary care. We don’t deal with
diagnoses. At least half of what comes to us is a problem. It’s not a
So they developed a matrix where, along one axis, you have the systems, the
systems as you know them from the ICD. And on the other axis, you have the
reason for visit, which as I said, half the time, is a symptom or sign.
But there are other reasons. “I need a prescription renewal. I’m
coming for follow-up of my diabetes.” I think they’ve got six or seven on
And they can code virtually everything that comes into primary care
according to what the patient’s problem is, not what you’ve called it. OK? It’s
in wide use throughout the world.
Larry, do you want to add anything to that?
DR. KLINKMAN: I can. Right now, I’m serving as chair of WICK. So we’ve been
working a lot with ICPC. I’ve been working with it in my institution in a
database that we have worked with for a number of years, and what Barbara said
is exactly right.
We’ll talk about it more this afternoon, if you want to know more detail
and how it might fit in a data model for primary care in a little bit more
comprehensive way here. So it’s coming.
DR. GREEN: I would like to add, Harry, the example that Barbara went by
very quickly there to just draw attention to what’s distinct here.
It is so different to record that the reason the patient is here is,
“I need a prescription,” as compared to recording a 250 number called
The first contact, longitudinal comprehensive care, to say the patient’s
here because of diabetes or for diabetes is not at all the same thing in terms
of the functions that have to be accomplished when you start off with they’re
here to get a prescription.
And then this classification actually allows you to channel these reasons
into a relatively small number of buckets that makes it practical.
Its design was to capture what in real life occurred with sufficient
frequency for primary-care clinicians to represent one percent of their work,
and then rag bags(ph) were created for all else.
So it captures 99 percent of the primary-care enterprise as seen from the
viewpoint of the patient. What a remarkable concept, if you’re interested in a
DR. STARFIELD: But it’s also used for follow-up. I mean, it’s not only the
presenting problem, because, you know, you need to know how the problem is
doing and follow up. So it’s across the spectrum of illness, and, also, it’s
compatible with the ICD.
DR. GREEN: Yes, that’s what I was going to say.
DR. STARFIELD: Yes, so one of those horizontal spectra are, in fact, for
diagnosis, and that’s compatible with ICD.
MR. REYNOLDS: But since our committee looks at electronic health records,
electronic — all the other things, is this coding system being considered for
the electronic health record — You know, I understand the payment. I
understand the ICD-10, the ICD-9, but is it being considered for the electronic
health records and everything that we’re putting together that are standard,
that are — you know — everybody’s certifying and saying it’s the right thing
Because if we’re talking about the medical home on one side and then we
talk about this is the way to maybe capture the information.
MS. GREENBERG: You wanted to say something, Michael, and then I’ll chime
DR. GREEN: Well, Harry, what I wanted to call attention to is this
committee, when Bob Hungate was still on it, recommended to the Secretary that
this be used in the electronic health record.
But then the answer is no, because apparently no one remembers or it hasn’t
been taken up from the point of view of the EHR.
It’s an idea that we have heard about here and talked about, but in terms
of actually getting action on this, we’re way behind.
And as Barbara said several times, it’s in wide use elsewhere, but people
in the United States don’t even know it exists.
MS. GREENBERG: Well, I want to follow up with you, Larry, as to a specific
recommendation you were referring to, because I’m not quite sure about it, but
I can tell you that going back to 1996, when the national committee updated the
uniform datasets for hospitals, uniform hospital — dataset, ambulatory-care
dataset, whatever — and I think Barbara was on the committee then. Yes. She
was on the committee for a long time, but — and also was an advocate, of
course, of functional status coding as well, which we don’t do, we don’t even
collect, for the most part, but — and the committee has recommendations on
But, in any event, in the updated core health-data elements, they
recommended — the national committee recommended collecting the patient’s
reason for an encounter in the patient’s own words, and did refer to the ICPC
as being a classification for that purpose.
And it is collected in the National Ambulatory Medical Care Survey, which
you’ll be hearing more about, I guess, this afternoon.
Also, as Barbara said, the ICPC has been mapped to ICD-10 and it is a
member of the WHO family of international classifications for reason for
encounter and for primary use by primary-care or family — I’m not quite sure
what the wording is.
And it was not one of the recommendations under the consolidated health
informatics initiative, but they didn’t actually ever address it, I mean,
address that particular, from my perspective, data element, the patient’s
reason for encounter.
And I think we have – there was – well, when was it? In October, there was
an excellent meeting — conference — you were probably out of the country,
Barbara, at the time but that was hosted by the Robert Graham Center, and
several of us participated in that, and then Michael and Bob Phillips, from the
Robert Graham Center, did come and report to the national committee on that at
the November meeting and talked about ICPC.
So I think the fact is that — and we talked about this a little bit
yesterday. There really hasn’t — the whole process of standards under AHIC and
HITSP, et cetera, hasn’t really looked at a primary-care use case, and so I
think the jury is still out there on whether it would be recommended for
electronic health records, and I have some ideas about how at least the reason
for encounter classification in ICPC could be kind of put in with ICD-10 CM.
So I think this is something for, obviously, more discussion, but there is
a lot of thinking about it.
MR. REYNOLDS: Thank you.
DR. STEINWACHS: Why don’t we go on, then?
And, Barbara, thank you very, very much.
DR. BREEN: Could I just ask one question?
DR. STEINWACH: Yes, please.
DR. BREEN: I apologize for coming in late, and I apologize to you, Barbara,
because I know that you’re the expert in this area. But this issue of whether
we classify encounters that don’t have a diagnosis associated with them seems
like a really critical underpinning, whether you think that primary care is the
way this needs to be conceptualized or whether it’s a medical home that you
need to conceptualize it, because, either way, we’re just — I think this is
underpinning the reimbursement, isn’t it?
I mean, we’re not reimbursing for these encounters, which, as you said, are
99 percent of encounters with primary-care physicians, because they’re
typically not diagnosing stuff. They’re encountering patients for something
else which may be a little bit more — it doesn’t have a classification
associated with it.
So it seems like this — this is a pretty —
MS. GREENBERG: Well, we are reimbursing for them. And, in fact, on an —
DR. BREEN: But at really inadequate rates.
MS. GREENBERG: Well, that’s another story.
DR. BREEN: I mean, we told some personal stories yesterday, and I am back
with my doctor, but I have federal health insurance, and I was actually kicked
out of my doctor’s office because their reimbursement rates were so low.
They finally renegotiated those reimbursement rates for primary care, but
it was at that point I realized that the primary-care services are reimbursed
way, way less than the specialty services, which is why the docs are going into
specialty services. It’s not that mysterious when you start following the
So it does seem like — am I right about this, that this critical
underpinning of reimbursement, there needs to be justification for these
encounters which are critical to people’s health and getting into the system in
the first place, which is an access issue?
DR. STARFIELD: Well, of course, it’s reimbursement, as most specialists
earn three or four times what primary-care physicians earn. Not the piece rate
that does it. It’s how things are priced in the system.
But that alone is not going to do it, because we’re really not training
primary-care physicians in our prestigious — Most prestigious medical schools
don’t have training in primary care, and there are systematic differences
across the primary-care specialties in what they train.
An internist doesn’t do the same thing as a family physician. Family
physicians are more — if you measure it, quantitatively, primary physicians
are more primary-care oriented in internal medicine even than pediatricians. So
we need another Flexner report.
You know, when Flexner wrote his report, 1910-1911, he recognized that it
was important to train physicians in psychosocial aspects, but he said we
didn’t have the scientific basis for that. That was a century ago.
Now, I think we probably at least have as much scientific basis for that as
we have for biomedical, but we’re still doing what Flexner said to do in 1910,
even though he would have, today, not said that.
DR. STEINWACHS: Thank you, again, very, very much.
DR. STEINWACHS: Our second presenter is Dr. Howard Underwood. And
is Dr. Keckley with you, too, or —
DR. UNDERWOOD: Unfortunately, he wasn’t able to attend today.
DR. STEINWACHS: Dr. Underwood is Senior Fellow at the Deloitte Center for
Health Solutions and will be talking to us about measuring the performance of a
DR. UNDERWOOD: Okay. I’m Howard Underwood. I’m with the Deloitte Center for
The Center for Health Solutions is an internal think tank at Deloitte. We
support the five major practice areas in Deloitte around healthcare solutions.
Our Chairman is Tommy Thompson, who you’ve probably heard of. He’s our
independent Chairman. Day to day is Paul Keckley, the Executive Director. He’s
a Ph.D. out of Vanderbilt. He started up the EBM Solutions, a big EBM kind of a
I’m a physician, ob/gyn — also an actuary. So it’s kind of a nice, natural
blend with my quantitative measurement as a clinician.
DR. STEINWACHS: So just a question. Did you get your actuarial science
training before your medical training or vice versa?
DR. UNDERWOOD: I kind of did both. I started actuary, then — a nice
Okay. So, today, actually, I have some things outside. This is a
point-of-view document that we created, Paul and I, just kind of describing the
medical home and kind of the value proposition, trying to quantify — and I
also have this little — if you want to subscribe to our website for upcoming
additional — pieces.
And, again, we’re independent. We’re not selling anything. It’s just we
want to tackle some of the most pressing, difficult issues in healthcare.
All of our topics focus around what Paul describes as the five
transformational themes in healthcare, around quality, looking as movement from
population-based medicine to personalized medicine and safety, those kinds of
issues around quality, demand management of which the medical home is a big
piece of that, healthcare information technology, leveraging efficiencies,
alerts, warnings, that kind of thing for information technology.
And then also critically looking at the physician-patient relationship, the
provider’s perspective around incentives, pay-for-performance, value-based
purchasing, and then around the patient’s perspective around the whole
consumerism movement, more rational purchasing of healthcare.
And, also, on our website, we just released a consumer health survey that
is a survey of consumers around kind of the population’s perceptions around
healthcare. So there’s been a lot of media hits out there, Bloomberg, CNN. So
you might have heard of that also.
But, anyway, back to today’s topic.
I’m going to talk to, first, kind of along with Dr. Starfield, just kind of
— the context of how we did this model, kind of primary-care practice versus
the future state of medical home, and then basically assessing the value
proposition, a benefit-cost kind of analysis to break-even scenario, and then
kind of so whats.
So to start, primary-care practice — and I think we all kind of know this
— historically, the PCP kind of runs the show versus in the medical home where
all of this is going to be very much a collaborative team with health coaches
and literally leveraging the ancillary staff to kind of bring a more holistic
care delivery to the practice.
Provider accountability, not as much incentives as we’d like versus what
Barbara is talking about, a lot of incentives around transparency and kind of
doing the right thing.
Physician’s role. Kind of the old days, a physician kind of possessed all
the knowledge, and, really, in the new medical-home model, really kind of being
a trusted source like historically, but also supplemented by leveraging other
people in the care team.
Historically, care has been fragmented. The idea here with medical home is
a more holistic, whole person point of view integrated, an anywhere, any time
facilitated with information technology.
Care coordinated. Historically, we could say it’s been disintermediated to
the disease-management and other medical-management vendors. And a new medical
home, it’s a reintermediation of that kind of function.
One of the issues in the current system is physicians get paid for volume
kind of — you know — getting people in, getting them out versus the medical
home more of a recognition for patient adherence and being rewarded on clinical
And then the decision support, largely, historically, has been the
physician-patient relationship, but in the new world kind of really leveraging
the information technology, EMRs, evidenced-based medicine for a more holistic
and rational process with the patient.
So getting into the model that I equated in our document, we had some
First, kind of that the components of the medical home, this whole
electronic medical record, with the registry function and also the
knowledge-management tools to really help physicians — clinical decision
support, evidence-based medicine, that kind of a thing — we estimated an
initial $80,000 to $120,000 upfront investment in the practice to get the —
kind of the infrastructure for the IT in place, the systems, and then an
ongoing $5,000 to $20,000 annually to maintain that system.
And, basically, the assumption is an evidence-based medicine,
clinical-decision support kind of a practice, looking at 300-million people in
the U.S. population and estimating at about a 1,000 to 2,000 panel size per
medical home. So 300 million divided by 2,000 patients is the estimate of
number of new medical homes.
With physicians getting reimbursed for care coordination, we estimated that
an annual of $50 to $100 per patient in the panel or, overall, about $100,000
to $115,000 in additional revenue for the physician in primary-care practice.
A major expense is the health coach, probably more like a nurse, maybe an
advanced nurse to kind of help with the care coordination with the physician.
We priced that at $78,000, and also added a 56-percent load to capture
benefits, coaching tools, et cetera, to kind of help the person do their job, a
data manager to make all the information systems kind of tick.
We didn’t think you would need one FT full time. We estimated about a third
of an FT, I think based out of Alan Gurell’s(ph) paper is where I got that, at
a $65,000 annual pay.
And then net contribution to the bottom line — to the gross revenue of the
physician or medical-home practice, we estimated $150,000 to $400,000
additional, that being historically kind of the PCP’s gross revenue is $350,000
In the new medical home, where with incentives and being paid for care
coordination, we estimated .5 to one million in gross practice revenue.
So those are kind of the base line cost assumptions we had going into the
And then, basically, the other side of the equation, looking at the value
proposition, in my article here, one of the frustrations in building the model
is there’s not definitive accepted ROI on disease management or case
management. In the paper I have a list from the Society of Actuaries just
listing all these studies where it’s kind of all over the place.
So the assumption was 10 percent fewer hospital admissions, 20 percent
fewer ER visits and — up to the hospital admissions, 10 percent less
absenteeism to kind of be conservative.
I assumed every ER visit had at least one diagnostic test and every
hospital admission would have at least two diagnostic tests, 20 percent fewer
And then kind of the bottom-line cost from the therapeutic perspective,
investing in the prescription is kind of like your typical disease management.
You pay for that, but the overall should make a dent in your medical cost.
So based upon the Dartmouth Atlas, where they identified a potential 30
percent variation across kind of the max and min of various centers, we
estimated potentially there could be a 30-percent savings with the medical
So the break-even scenario – I kind of alluded to this – that the critical
medical cost drivers were the health coaches and kind of the increased
effectiveness of their enrollment in disease-management programs.
Some of the Deloitte internal research, we typically see about 10 to 15
percent of eligibles — the predictive models actually enrolling in disease
Our assumption was with the medical home, it would increase the
actionability of those people since the physicians are going to be more engaged
and more aware of what’s going on with that patient, so we were kind of
aggressive assuming that 75 percent of those people who were eligible would be
And then we also assumed — baseline, historically, it’s been about a
15-percent enrollment from eligibility into the enrollment for disease
management, case management. We assumed a 50-percent increase, again, due to
the medical home. So that would bring it up to about 22.5 percent of eligibles
would ultimately be involved and acted upon in the medical home.
And so, with that, health-codes management at 250 — disease-management
patients, on average, talked about $250,000, we assume medical costs trend of
eight percent per annum, non-medical cost trend four, our model estimated about
four years to break even. So the hurdle is that upfront initial investment of
$100,000-plus to kind of get the wire infrastructure in place and then really
kind of getting the bang for the buck after that within four years to pay for
these systematic investments.
Might be kind of hard to see – (laughter)- comes out of this, and all of
our thought ware, this is one thing Paul always stresses with me kind of like
talk about the context, the history, kind of lay the — this is kind of where
we really kind of make the major contribution.
We look at kind of the stakeholders, kind of what’s in it for the
stakeholders, and this is looking at the PCP, the primary-care physicians, the
large, multi-specialty groups, health plans, the employers, life science
technology companies and then the public sector, the state government and
federal government. So we just kind of bullet here some of — you know, what
are the key implications by those stakeholders and talked about before largely,
the PCP, it’s going to really kind of rejuvenate primary-care medicine.
Like I said before, the initial hurdle is that $100,000 upfront investment,
which is kind of a big piece to bite off.
As an implication, we said that there would need to be some kind of a
long-term bonus structure, upfront capital from a strategic partner to
operationalize this model to support coordination of care and patient
At the hospital, the hospitals would more likely lose in this, and we
estimate about a 30 percent savings in cost, largely due to the 10 percent
fewer admissions in the hospital, 20 percent fewer ED visits.
So our implication was it could potentially risk relationships with
community-based specialists, this medical home, as their traditional referral
network kind of takes a hit.
But then it really kind of depends upon the community’s perspective or the
mission of the hospital in that community. A place like Geisinger might have
kind of a different mission versus other kind of places. That would need to be
kind of kept in context.
And, really, medical home — talked about is this moving from a
community-based chronic — to a chronic and preventive kind of a program as
opposed to the prior acute kind of a thing.
Commercial health plans perspective. Potential, again, to shift the cost
from the acute care to the preventive and chronic, but this could also be
unsettling to the community, and especially if there’s kind of like one major
dominant health plan in town, there could be a perception of — between the
traditional patient practice dynamics, but this also could be a positive
disruptive innovation to really kind of help move the model to have a more
cohesive integrated healthcare system.
And then public payers, largely the same thing as the commercial payers.
It’s really about rewarding providers around P for P to effectively coordinate
care, be a direct accountability to the patient care and strengthen the
So moving forward, what’s it going to take to make the medical home happen?
Some of these issues or challenges we highlighted in the paper.
One thing is most physicians lack training and experience in implementing a
medical home. Doctors go to medical school probably not for developing systems
and kind of business like some of us. So there could be some challenges along
It could be an opportunity to partner with local healthcare systems and the
health plans to leverage economies of scale to tap into some of their expertise
to, again, have that more cohesive healthcare delivery system.
We also thought that — again, kind of talked about this before — with
evidence-based medicine serving as to medical home’s life blood, what if a
physician practicing EBM has a bad outcome? There needs to be some kind of a
consideration maybe to medical courts to address implementation of EBM even
though not all the time you’re going to have a good outcome.
Also, the medical home is going to aggravate the shortage of primary-care
physicians. So a comment here we had was Randel’s(ph) prescription for
Pennsylvania, how he’s broadening the scope of the ancillary providers. So that
would be a way to kind of help that. If the medical home kind of got the
traction, put that demand on the system, we need to kind of broaden the scope
to other people to help with that.
And then issues around — talk about the healthcare information technology.
I mean, we were just really kind of really thinking out of the box here.
Life-science companies needing to scale up medical devices, medication
technologies to support — care coordination. Could the electronic power grid
handle this surge electric activity in an information kind of a system?
Touched upon this also. Potential turf wars between providers and the
disease-management vendors and health plans as the providers kind of maybe get
back into that care-coordination space.
But despite these issues, we thought there was a compelling argument to
support the medical home. It’s a better delivery model with the history of
Wagner’s chronic-care model with the more holistic comprehensive approach to
It really kind of affords those teachable moments with physicians when you
had the patient in your office and you had that kind of a relationship you can
really be more effective, and that was kind of the purpose of the 75-percent
assumption in our model.
Really need to address this healthcare reimbursement issue, more adherence
to evidence-based medicine as opposed to the volume-driven system as it is
And talked about kind of the opportunities to foster more relationships
with hospitals and other large companies to facilitate the economies of scale.
And, bottom line, also in our global workforce, it offers a more productive
and competitive workforce to make the country that much more competitive in a
So that’s kind of the summary of our paper here, and are there any
DR. STEINWACHS: Howard, thank you very, very much. Let’s open it to
questions and comments. Matt.
DR. QUINN: One of the tools that we saw yesterday, the PPC PCMH, which is a
version of it, which is being adopted by CMS, talks about different levels of
primary patient-centered medical homes, Level 1, 2 and 3, more mature
Can you talk about the distribution and the movement of organizations or
practices through those levels and how that would effect the assumptions in the
DR. UNDERWOOD: Yes, the assumptions are really kind of leveraged through
the existing literature by the Society of Actuaries. So there’s about I think
anywhere from like $100 to $200 PMs. We kind of brought that into the model,
but then that’s highly variable. Some disease states aren’t positive — et
So in regards to your question, the thinking would be along those levels of
the medical home that the experience — I think it would be like any kind of a
new kind of an operation. You’re going to have that initial setting things up,
kind of learning, getting the processes in place versus kind of the old stages
of managed care up to the final state.
So I would suspect, kind of similar to some of what I’ve seen in other
places around disease management measurement, you probably would have kind of a
— kind of like the asintotic(ph) up and then kind of a lot like a product
lifecycle kind of a curve, you know. You’d have a big bang for the buck kind of
at the low-lying fruit. Eventually, you’re going to hit kind of the tip and —
economies of scale would kind of — in. That would be my guess.
DR. FRANCIS: I heard a different theme in your conceptualization of the
medical home from themes I’ve heard before, and I just want to ask whether what
I heard was accurate.
Sometimes models, where there’s a lot of health coaching, are paternalistic
and potentially almost a little coercive for patients; that is, the expectation
is that you receive the coaching and there are either financial incentives
built in or actually differences in whether you can receive services, depending
on your level of “compliance.”
And I wonder whether, as you conceptualize the medical home, it is more
aggressively paternalistic than a coordination mechanism might be.
DR. UNDERWOOD: And I would say our assumption was kind of more middle of
the road. It’s all about getting the incentives in place, and we didn’t want to
assume paternalism. We wanted to kind of have the right consumerism kind of
decision support tools, incentives in place to really facilitate the right
patient and also provider behavior.
But the assumptions was based upon what I found in the literature, kind of
like the population averages, so kind of at that middle kind of an assumption.
So neither too paternalistic nor too laissez-faire. Kind of that middle road.
DR. FRANCIS: You were envisioning practices in which — well, the coach is
there if you want to take advantage of it, but there are no implicit or
explicit requirements for patients to do that, as part of getting care from the
DR. UNDERWOOD: Exactly. Right.
DR. CARR: Yes, thank you. Thanks for a great presentation.
I’m juxtaposing the first presentation from Barbara on these ankle setting,
bone fractures and immunizations, and those activities with your assumptions
about the care being delivered, and, actually, thinking also to yesterday’s CMS
demonstration project where they’re excluding a lot of folks, including only
those who have chronic care and a certain number of conditions.
So I think we’re hearing about a continuum or a spectrum or different views
of the practice, whether it’s — you know — the primary care as outlined by
these 14 frequent activities of primary care to more chronic disease
And I wanted to ask what are your assumptions about the balance of
activities such as described by Barbara versus the chronic-disease management
in your financial model?
DR. UNDERWOOD: Yes — the model is, again, kind of just leveraging what I
could find in the way of data that was out there. I mean, that’s what the
center is all about is let the data kind of tell the story.
So I didn’t have — I mean, the DM data wasn’t necessarily the best, like I
talked about before — all over the place, but even getting to Barbara’s
description of primary care, even that — data was even less kind of concrete.
So just being conservative in the model, we just built in the traditional
DM kind of programs around CHF, COPD, asthma, diabetes, kind of traditional.
Just look at those as kind of the minimal set for the patient-centered medical
home thinking that a real medical home would do even more than that. So this is
just a very conservative, based upon the chronic disease kind of a view, a
four-year kind of a break even versus a broader kind of true medical home
should be a quicker payback.
DR. CARR: Thank you.
DR. STEINWACHS: Other questions? Harry.
MR. REYNOLDS: Yes. As I’ve listened to the number of presentations over the
last couple of days, everybody says “medical home,” but it’s coming
across to me that whoever says it has their medical-home definition.
And so one thing I think you could help me with as I look at the investment
that you mentioned — the $80,000 to $100,000 — is that just in the
Because, obviously, for the medical home, as we’ve heard the presentations,
it means that they’re coordinating the care and information about other things
that that patient does, if that patient was in the hospital, if that patient
saw a specialist, if that patient did something else.
So as I look at your investment, is that just in the primary-care setting
or is that — because, you know, one specialist could be working with multiple
— could be seeing patients from multiple medical homes and the information’s
gotta flow, the coordination’s gotta happen.
And so I can’t figure out from your model whether or not you’re just taking
care of that primary-care setting and the rest of them need to step up in some
other way or how did you see that investment?
DR. UNDERWOOD: I was looking at it from a single medical home’s
perspective, but then the physician would be very much engaged in the hospital
setting, kind of managing that global-care coordination, but was really kind of
that — the 300-million patients divided by 1,000 to 2,000 patients in a panel
resulting in 150,000 new medical homes. That’s how we constructed the model.
DR. STEINWACHS: Howard, on the model, one question from me was if not
everyone wants to be in the medical home, is there a mixed model there that a
physician’s practice could be a mixture of people in the medical home and
people not or is this a little bit like what you — when you hear about
concierge medicine, you usually hear about someone changing their total
practice, and so either you’re a patient in my practice and you are part of the
concierge model or I’m not going to see you in my practice.
And CMS was talking about willing providers and willing patients which sort
of talked about the potential to have a very mixed model where you can have
some subgroup who were getting the comprehensive medical home services, others
who be more traditional services, still, hopefully, comprehensive, but not
having some of those pieces that enhance continuity, your health coach, other
DR. UNDERWOOD: The model I have here is — again, it’s kind of the
actuarial perspective, so it’s built upon averages, like they talked about
before. It’s not too paternalistic. It’s not too laissez-faire, kind of the
average. So there’s meant to be a continuum in the model. So there would be a
natural — you know, some patients may be opting out.
Like I said, historically, it’s about 15 percent of eligibles ultimately
make it to disease-management programs.
So kind of moving up the impact — that’s where I saw a lot of the
opportunity, but, yes, you can have people that aren’t going to be fully
DR. STEINWACHS: I guess the challenge for the primary-care provider, then,
would be how do you make it economically viable if you are — the investment of
the $100,000, essentially, you can’t avoid, even if only half your practice is
in the medical home, I guess, is that sort of — The business side of it gets
tougher, I imagine, and the —
DR. UNDERWOOD: Yes, and that’s — especially that the primary-care
practice, the thin margins and talked about maybe hospitals or health plans
where — above the plate and help out.
DR. GREEN: Well, Don, I wanted to react to your question and ask you to
correct this if it’s wrong.
I believe built into the models that Deloitte used is empiricism that’s
based on experience in various care settings in the United States in various
periods of time in various settings for various conditions.
Under those assumptions is the reality that the way people use healthcare
now, and the way they were using it over the last 10 or 15 years, is
selectivity. Forgive me for behaving like a physician, but, I mean, patients —
DR. STEINWACHS: Maybe I’ll forgive you, Larry. I don’t know.
DR. GREEN: People decide to make that great leap of faith and become a
patient for all sorts of reasons on any given day, and one of the fascinating
things about medical practice is discovering why someone shows up when they do.
You know, they should have come 18 years ago and they didn’t. You can’t figure
out why there’s any need for them to be there in the first place today, you
know. Could you just move on along?
I believe the Deloitte model has built into it a presumption that there’s
differential use by individual patients of these services, always has been, and
I believe it assumes it always will be, and that the idea of — well, you know,
are we making people use healthcare services as they claim to have a medical
home? I don’t see that that has viability as a concept.
DR. KLINKMAN: But on the flip side, I think, from the perspective of an
office, if there is to be a whole set of competing technologies or competing
processes or competing services that you pick from because of it being offered
by one specific carve-out vendor versus another vendor, and those change by
health plan to health plan, the investment that a practice makes is totally
lost. It’s just too much complexity for a practice to deal with.
So, at some level, my way of thinking, from the perspective of a person in
a practice, is, there has to be a standard set of approaches that we use.
It’s a one-size-fits-all in terms of the process that we undertake as
primary-care, medical-home providers. It can’t vary by payer or by specific
disease. We can’t have five different carve outs for five different diseases,
because the next disease will have its own new disease-management protocol that
And if we have to reinvent ourselves as clinicians in the processes we go
through for these things, it all collapses. The complexity is just too much to
manage in the constraints of primary care.
DR. STEINWACHS: Well said.
Well, Howard, thank you very, very much. This is helpful, because it really
talks to some of the fundamental issues of rolling out and making it feasible
to have a medical home.
DR. STEINWACH: I’d like to move on next to Dr. Reva Winkler, who’s with the
National Quality Forum.
Reva, where are you?
DR. WINKLER: I’m right here.
DR. STEINWACHS: Oh, there you are. Thank you.
You can see I’ve reached the age where the eyeglasses don’t do it,
sometimes, I guess —
Justine is here whispering to me about the primary-care services she’s
going to offer me shortly, so that I won’t be –
Agenda Item: Care Coordination: Moving Towards Practices and
DR. WINKLER: Thank you very much for the opportunity to come and talk with
you today about some of the activities at the National Quality Forum.
The National Quality Forum is a private, non-profit organization. It’s a
membership organization of over 350 organizations representing a wide spectrum
of stakeholders in the healthcare arena, including consumers, purchasers,
professionals, providers, quality organizations, researchers, supplier industry
and government agencies.
We are a voluntary, consensus-setting standards organization focused on
endorsing performance measures within the healthcare field.
We’ve been around for about eight years now, and we’ve endorsed performance
measures that are widely used by CMS, the joint commission, various national
organizations, both for ambulatory care, for hospitals, nursing homes and a
wide variety of aspects of healthcare.
One of the issues, whenever we’re looking at areas to measure, that rises
to the top of every priority list is care coordination. It has for years.
NQF’s first activity on care coordination, first attempt at trying to find
some measures to endorse, occurred about three years ago as part of our large
ambulatory-care project. It was the top priority area. There were 10 identified
areas. Some were condition specific, but four of them were cross-cutting areas,
not condition specific, and the big one was care coordination.
Unfortunately, three years ago, when we were searching the universe for
potential measures to evaluate and consider for endorsement, there was a
relative dearth of anything out there that we could really feel comfortable
represented the stakeholder’s view of what care coordination is.
And so, as a result of having nothing to endorse, we used our resources to
consider what — trying to understand what care coordination is and how we
might approach a measurement strategy to — for care coordination.
And so, as a result of that activity, NQF has endorsed a care-coordination
framework for measurement to try and understand what is this beast and how
could we get our arms around it to begin to develop measures and ultimately
endorse a set of measures that would help assess the ability of the healthcare
system to coordinate care.
And so our care-coordination definition, as a prerequisite to developing
the framework, is in front of you.
It’s a function that helps ensure that the patient’s needs and preferences
for health services and information-sharing across people functions and site
are met over time.
And this is deliberately and explicitly a patient-centered approach.
The framework encompasses five domains and four principles. The five
domains represent essential components for which performance measures should be
developed to drive improvements in healthcare, and the fist domain is the
Three years ago, the nomenclature was a little less standardized if (sic)
it is today, and so we kind of used the term “healthcare home,” but
it is meant to capture the evolving concepts that the American Academy of
Pediatrics, the American College of Physicians, the American Academy of Family
Physicians have pulled together as the medical-home concept.
The other domains include a proactive plan of care and follow-up. Another
domain is communication. Another one is information systems. And another one is
the transitions or handoffs that I think everyone knows is a particularly big
concern in care coordination.
The principles for care coordination that go along with those domains are
that care coordination is important for everyone.
It is quite conceivable that a young, healthy person will break their leg
skiing, end up in the hospital with surgery, need rehab follow-up, and, for a
limited period of time, need care coordinated, maybe not for years, but
certainly for that acute event.
And so care coordination is not necessarily something that is for
specialized populations, but is ultimately important for everyone.
However, it is well recognized that some populations are particularly
vulnerable to fragmented and uncoordinated care and particularly deserve and
need the benefits of well-coordinated care.
The framework presents the domain such that it’s suitable for measurement
and accountability at multiple levels, including clinician level, but,
certainly, at the home level, at group levels, at population levels.
All of them may have aspects to contribute where measurement at various
levels are appropriate to really get a good assessment of care coordination.
And then patient and family surveys of experience with care coordination are
essential. They are a pivotal outcome of well-coordinated care.
So we can talk about these various domains in a little more detail, if
you’d like, but healthcare home is essentially that — the generalized concept
I think most of us understand, usual source of care selected by the patient.
Function is a central point for coordinating care around the patient’s needs
and preferences. The medical home should coordinate between all various team
members and non-clinical services as needed and desired by the patient. Again,
very patient focused. This is sort of a shared partnership concept.
The next domain is a proactive plan of care where the plan of care for the
patient anticipates routine needs, actively tracks up-to-date progress towards
patient goals. This is shared decision making and care management.
Communication, an essential aspect of care coordination. Communication
available to all team members — and that’s healthcare team members —
including the patients and the family.
Starting to really open up that communication and sharing of information
among all of the team players to include the patient and family as active
participants. Information systems are an important domain to facilitate
information transfer, patient tracking and care coordination.
The interoperability, the decision support, the safety and efficiencies
that the tools information technology can bring into it is an important
characteristic of care coordination.
And then transitions and handoffs are another aspect that I think everyone
understands is particularly problematic. Transitions between settings of care
are fraught with any number of problems where mishaps can occur, particularly
around medication, follows-up to tests and services, changing the plan of care,
involvement and communication between the team in the hospital and wherever
else and communication among all settings of care.
Following a patient from a typical hospitalization to rehabilitation to
chronic care to home health care back to the ambulatory care or any little jogs
back and forth between those care settings is extraordinarily common and not at
all well handled.
So in a world that we’re looking forward to, we would be looking for
performance measures to assess the elements and characteristics of each of
these domains to try and understand how well care is coordinated for patients
and for populations.
How are we doing? Well, okay, in terms of measures and despite the
incredible interest by everyone about care coordination, the measures aren’t
coming easily, and it’s a difficult and complex problem.
The first measure that NQF — really the only measure to date that NQF has
endorsed around care coordination is the care transitions measure. It’s a
three-item survey tool. It’s envisioned to be tacked on to typically survey
tools post hospitalization asking, again, patients and families, “How’d it
go? What happened in terms of transitioning from your hospital stay into your
It is by no means sufficient to truly understand the complexities of what a
transition is, but, to date, that’s the measures we’ve been able to identify.
Hot off the press. We released these last Friday. We have just released
four public comments, some potential structural measures about health
information technology that will address some of the technological information
aspects of the care coordination framework.
I’ve listed these — the nine draft measures. These still have to go
through the rest of the consensus process before they will be endorsed. So it’s
not a done deal yet, but they do include things of adoption of medication,
e-prescribing, adoption of HIT, the ability to use HIT for care management,
tracking of laboratory data, tracking of clinical results between visits,
participation in registries, and then also is the PPC, the PCMH survey tool
that NCQA has.
And just to be perfectly clear, what we are — in the draft proposal to be
endorsed is the actual tool itself, not the program around which that NCQA has
created for recognition. And so it is the survey tool checklist instrument
only, and this is something that is publicly available that groups or practices
could utilize to assess their own practice characteristics.
So if we look at the care-coordination framework, the various domains and
where we are in terms of endorsing measures, you can see that we’ve really only
made a minimal inroad into transitions.
These new proposed HIT measures may provide some measures for the
information systems domain and the healthcare home domain, perhaps.
Maybe there’s some elements of the communication and plan of care with the
decision-support and care-management tools, but, as you can see, we’ve hardly
scratched the surface, and it has been three years since NQF has done its last
search for measures.
We are now launching our next project. It is hopeful that there have been a
great many activities among a wide number of stakeholder groups trying to
address the issue of care coordination. How do we get our arms around it? How
do we measure it? How do we assess it? How do we know it when we see it?
And so within very short term we will be announcing calls for measures, and
we encourage anyone who can help us out with this to please let us know and we
certainly welcome your input.
DR. STEINWACHS: You have me thinking whether it’s half full or half empty,
Reva, but thank you very, very much, because you’re right. This is critical to
what we think of as the medical home and primary care.
Let’s open up for questions, comments.
DR. BREEN: Listening to all of the speakers, it really strikes me that, for
this to be implemented in less than 40 more or 90 more years, it’s going to
have to come together somehow, and I’d like to see it come together as a
structure, as a system.
And so that’s going to mean that there’s going to need to be some grouping,
some ways of working together or at least in a way that’s parallel.
I mean, right now, everybody knows we’ve got a bizzion different insurers,
a bizzion different forms. I mean, it’s — people are spending an enormous
amount of time doing peripheral things to providing care, and that’s troubling
to people, and we haven’t figured out how to resolve it.
And one thing that was striking to me in the model — and I don’t think the
others spoke about it, either Reva or Barbara — but the model that Howard
presented was there was, I think, an assumption — When you talk about 1,000 to
2,000 patients, that sounds like a physician or a physician practice, and I
know you want to add to the physician some axillary — I’ll use that term. It’s
not the best, but, you know, additional providers that would work with the
physician as a team to accomplish this.
But, still, I’m thinking that when you put them together, if, say,
physicians were not practicing solo, which we heard yesterday about 50 percent
are, then you do get economies of scale. I mean, you can start to work
And it also strikes me that, periodically, I’ve been hearing that
physicians would be working with other types of physicians. In other words, the
primary-care and the referral people might be working in the same premises as a
group practice or something along those lines.
We also have HMO models that are existing in the country, group and staff
model. I would call those HMOs. The others, I wouldn’t really call HMOs.
But I’m wondering — and then the other thing, there was the amount of
money in the model — because you were the only one that talked about money,
Howard — was the amount that it would cost — and it didn’t seem to assume
that we were already spending quite a lot. So I think there’s a marginal amount
that might be quite a lot less than what you were saying. Maybe I’m wrong about
that, but, anyway, could you talk a little bit more about the structure or how
this would move forward?
And I know the National Quality Forum tries to do it by consent among
providers to sort of get buy-in and then have everybody sort of track
themselves to see how they’re doing, and that has yielded some progress. It
definitely has, and it might in this, too.
But are people thinking about structures at all or how this might evolve?
DR. UNDERWOOD: I just saw something the past weekend, Southeastern
Pennsylvania, with Aetna and Cigna. I think it’s similar to the
pay-for-performance movement. It’s going to be largely from the payer to kind
of drive to make it happen.
I just don’t see physicians, facing $100,000 investment, they’re just going
to sign up and do this, would be my take on things.
DR. WINKLER: You’re absolutely right that at NQF the various
multi-stakeholders try and kind of reach agreement on things.
Care coordination is such a high-profile topic for us that our spring
membership meeting in Atlanta in March was a two-day meeting around care
coordination around the elements of the — the domains of the framework, and
each of our member council stakeholder groups was asked to seriously think
about action plans that their particular part of the game could facilitate
moving — in encouraging, in facilitating it.
I do think that this is part of a bigger concept around the goal of
transformation. And transformation going from something really significantly —
to something really, really significantly different than what we’re used to is
both hard, complex and needs all the incentives align, and it’s not going to be
— it’s neither going to be quick, nor is it going to be neat. It’s going to be
But I do think that what — in order to get there, it’s going to take
something fairly huge — what I would consider transformation to be. Changing
structures. Changing payment systems. Changing relationships. Changing our
MS. GREENBERG: OKay. I don’t know so much that I have a question as a
comment, and I would say isn’t probably unusual, but, yesterday, I had a
clearer idea of what we were talking about than I do today. (Laughter). May be
a reflection on me, but I also think it’s probably — Are there other people
who feel the same way? So I think that it shows the complexity of all this.
And one of the things that I was trying to do, as Reva was talking, is
looking at her slides and then looking at Barbara’s points and trying to say,
“Well, all right, coordination. We all seem to be clear on coordination,
but could this really mean that or could — “
So I guess what I’m thinking is that this committee is not explicitly about
health-system transformation. That’s not our charge, though I think we all
believe that information is needed to transform an individual practice, all the
way up to population health. So that’s where we come in.
And so what we’re — our link into this has to do with what kind of data
model is needed to make what we — even though we’re all using different terms,
and medical home — I thought, after all the reading I did and after yesterday,
that medical home and good primary care were really close to each other, and
now I’m starting to think they’re not so close to each other, though they
certainly have things in common.
So whatever we decide is cross cutting here, what is the data model and
then what type of information would you need to define that these features are
there and then to evaluate them and to measure them. And I think that’s —
hopefully, that’s where we’re now going to be looking at, increasingly, in the
rest of the day.
But I think, as long as we’re talking about really different things or
different pieces of things, then how you measure it, of course, is a real
problem, because you have to agree on what you’re measuring and on the
So these are just some thoughts I’m having that we’re kind of getting —
you know, as I realize that these are not the same things and that everybody —
as somebody mentioned, when they use the term, they all have a different idea
in their mind.
I think this will certainly increase our challenges for measurement, but I
think the data model is so important, and that’s what we concluded at that
primary-care classification conference, and I guess we’re coming back to that.
So just something to chew on over your coffee break.
DR. GREEN: Well, I think Marjorie reflects the list of stages of project
development I have on my office wall. Starts with wild enthusiasm, and the next
phase is disillusionment. The third phase after that is search for the guilty,
and so watch for that coming up next.
But I wanted to ask — if she wouldn’t mind, I want to ask Barbara to weigh
back in here, having heard Reva and Howard speak about their approaches and
Barbara, I heard you emphasizing the crucial aspects of longitudinality and
comprehensiveness for the medical home, and intersect that for me with what the
National Quality Forum is working on and what Deloitte worked on, if you can.
DR. STARFIELD: You’re asking me?
DR. GREEN: Yes.
DR. STEINWACHS: He’s putting you to work again, Barbara.
DR. STARFIELD: And what if I say I don’t know?
Well, you know, there’s such a huge literature on this that — I mean, it
seems to me that one of our problems is that we’re a generation behind the rest
of the world in concepts, and it’s very hard, in the modern world, where we’ve
got all this modern technology, to be so far behind in concepts.
So, you know, there was a beautiful report on care coordination that was
prepared for ARHQ, and it’s got everything in it, just everything in it. And
Ellen Nolte and Martin McKee are doing something similar in UK.
I mean, we know so much about this stuff, I don’t — It seems to me we need
to talk about functions, not about structures.
You know, what we’re doing, I think, is trying to make a new business. You
know, a lot of companies and firms out there are wanting a new niche, and we’re
talking about the product. We’re talking about the structures and we’re not
talking about what it is we want to accomplish. So I’m completely lost.
MS. GREENBERG: Oh, good. I’m not the only one.
DR. STARFIELD: I’m going to go back abroad. I mean, it’s frustrating to be
so far behind. There’s so much literature out there. We know so much and we’re
just not using it.
DR. STEINWACH: Dr. McGeeney.
DR. MC GEENEY: I’m always reluctant to talk to the guests, but a couple of
comments from yesterday, there is a lot of confusion around medical home, and I
think, with my academy hat on, one of the things that we’re spending a lot of
time on, there’s a very strong difference between chronic disease management
and medical home, and those two terms are, unfortunately, getting used
synonymously a lot.
Now, there’s absolutely no question that chronic disease management is a
very, very important part of medical home, but, as we talked about yesterday,
it’s all the other pieces of the medical home that really are going to make
chronic disease management successful.
What Barbara is talking about is what we would really like to see,
integrating primary care with medical home, but there’s an awfully lot of work
to be done, but I think that truly is the goal, but we’ve got — you remember
that thing I showed yesterday with eight different boxes. Chronic disease
management was one line in one box, and we’ve got to kind of remember that.
The other thing, on the transition thing, and thinking about a whole
different system, wouldn’t it be cool if just the primary-care doctor could see
the hospital record to know what was done, and the ER doctor could see the
hospital record and the primary-care record?
None of those things ever occur in the real world, but even that would make
a huge difference in transition of care.
So it’s a system, it’s a process, a totally different way of doing things
that we need to think about.
But chronic care and medical home get blurred a lot, and that’s where a lot
of the confusion comes in.
DR. STARFIELD: Yes, I’m glad — let me just mention that. I mean, by
definition, primary care is not disease oriented — by definition. So to talk
about chronic illness just makes no sense. I mean, that’s a whole other talk
that I have, the foolishness of the concept of chronic illness.
I mean, that doesn’t mean that diabetes and hypertension aren’t important,
but to focus on illness is just the wrong way to go about the health of
And, you know, we all know that we’re about thirtieth in the world in the
health of the population, however you measure it. We’re clearly doing something
DR. WALKER: I’m going to talk about this some this afternoon, but I think
part of the issue is that, certainly, what we’re trying to do is transform
health and healthcare, and that’s bigger than primary care. It’s bigger,
certainly, than medical home or than chronic-care management.
And it seems to us, at least, that if we get the end processes of care
right, that go all the way from population screening to end-stage care, and we
are able to offer to each patient what is appropriate, the range of things that
might be appropriate to them, and keep track of what they’ve decided with their
physician they want to do, and help them manage getting that done, at whatever
level of intensity that requires — and it’ll be different for different
people, different stages of their life — that if we do that, then we will have
succeeded, and we believe that we will have achieved the goals of chronic-care
management and going to learn more about primary care and about medical home,
but working in a different kind of a fundamental set of structures and
processes and outcomes.
DR. STEINWACHS: And that’s helpful.
DR. TANG: Try to bridge between the primary care and the chronic-disease
management by creating another term, “chronic-condition management,”
and let me see if this will work.
If you could do chronic-condition — the reason I label it
“condition,” because sedentary lifestyle, obesity, lack of healthy
behavior is a chronic condition, but it’s — i.e., it’s a lifelong, it’s a
continuous kind of a thing that we have to manage mostly by ourselves; i.e.,
the patient or consumer.
But if you could do that well, if you could assist the consumer/patient in
doing chronic-condition management, then I think you will have enveloped the
components necessary to do primary care.
So in trying to separate the two, I understand what you said about they’re
not the same thing, but how could we think about it if you had in place the
components that could create this relationship with the patient that turned
over health management with our ancillary support — i.e., the healthcare
professionals — and the tools, then I think we will have put in place a way
that patients can take a more active role in maintaining their health.
I’m just trying to put together a way to think about the two and find a way
— if you’ve got one of them, would you get the other.
DR. BREEN: I just wanted to ask Paul Tang a question. Do you think that
obesity and some of the chronic conditions that children have — this big piece
yesterday and also today in The Post about it. Do you think these are
because we don’t have good medical care?
DR. TANG: No, I think it’s because we don’t treat health as an activity of
daily living, and I think that we have tools that could help how people deal
DR. BREEN: Okay. Thanks for the clarification.
DR. STEINWACHS: I just want to make one comment that, Barbara, I think you
were talking about how coordination in a primary-care context is fundamentally
following up on problems over time and that can also be across settings, I’m
And I was trying to relate that some to Reva’s framework which has elements
that are follow-up, depends on what you think about them, and I was — So,
Barbara, do you see the follow-up concept is a sort of a unifying one or is
DR. STARFIELD: Well, in this country now, there are more visits to
specialists than to primary-care physicians, especially among the elderly. The
elderly see far more specialists than they see primary-care physicians. And
hospitalizations, of course, are going down still.
Mainly what I’m talking about is coordination between primary care and
secondary care. Hospitalization comes into secondary care.
You know, we don’t even really know what the functions of specialty care
is. We’re not even addressing that issue. We don’t know what’s in the domain of
specialty care, what’s in the domain of primary care. And this is what I mean
when I say we’re so far behind, because they’ve been discussing that for years
So, no, I’m not only talking within primary care. I’m talking about when
people do have to go elsewhere. I mean, I think primary care has to be more
comprehensive, but people do have to go elsewhere for things that are not
So it’s mostly in that context that I’m talking about coordination, which
is not that different from what you’re talking about.
DR. STEINWACHS: Thank you.
We have scheduled a break, and I think that’s probably the humane thing to
do for everyone here.
So why don’t you take about 10 minutes and then we’ll come back and
DR. STEINWACHS: Well, it’s a great pleasure to have Karen Boudreau with us.
Dr. Boudreau is the Medical Director for Healthcare Quality Improvement at
Blue Cross Blue Shield Massachusetts and also a family physician and a clinical
instructor at Boston Medical Center, and I think you are developing a system,
is that —
DR. BOUDREAU: Yes.
DR. STEINWACHS: And then will be followed by a discussion from Geisinger
about their system. So we’ll get a sense of systems as they are evolving,
trying to meet some of these challenges that we’ve been discussing.
Karen, thank you for being with us.
DR. BOUDREAU: Thank you very much, and I hope to not add to the confusion
but this is a very complicated topic.
And I’m very grateful to be here. Had a nice flight down on like a 30-seat
plane, which was kind of interesting in the rain, but we made it. And I come to
you, as you mentioned, as Medical Director for Quality Improvement, but also as
a survivor of primary-care redesign round one.
My background is as a family physician. The first 15 years of my career
were in Western Massachusetts practicing with a multi-specialty group that was
part of Kaiser Permanente when they actually existed in the northeast. Many
people don’t know they were there for a long time.
And in the mid-1990s, we went through a process of primary-care redesign,
kind of around evidence-based medicine and teams and providing more
comprehensive care than we had been previously.
This was in the days before we had a lot of quality measurement, before —
we didn’t know as much about how to measure processes of care, et cetera, and
what was important.
So I come with that background and hope that some of the learnings that I
had through that can be applied to what we’re doing today.
Just a very little background about Blue Cross Blue Shield of
Massachusetts. We are one of the top-rated plans in the country. We share, with
several other Massachusetts plans, the honors of being, at various years, any
one of the top four or five plans in the country.
We are a large plan with three-million members. About half of those — just
under half of those are in national accounts, which means that they may not
live in our state. We ensure them, but they may live in — I always pick Iowa.
I don’t know why. Iowa or Idaho or Alabama, anywhere around the country, but we
are responsible for providing their insurance.
And about one in three Massachusetts residents is a Blue Cross Blue Shield
We have a very large physician network, about 24,000 physicians overall,
about 8,800 are in primary care. That’s a little deceptive. With four medical
schools, we have a fair number of very part-time practicing physicians,
including myself, who sees patients only half a day a week now.
So I would say it’s more down around the 5,000 level that are people that
are really fully engaged in primary-care practice on a routine basis.
And our company has really built a reputation for commitment to quality and
safety, supporting quality and safety initiatives.
We sponsored the Massey Health Collaborative, which is wiring three
communities in our state to all be on electronic medical records and with
interconnectivity and measurement. We’re learning a lot from that. Complexity
is just overwhelming. We’ve also sponsored an e-prescribing collaborative, and
Massachusetts is now the number one e-prescribing state in the country, and
that has achieved a lot of very important safety improvements, I think.
We were very involved in the healthcare reform activities in Massachusetts,
looking to get universal coverage for all Massachusetts residents. Many people
have many opinions about that, but we do think it’s very important.
And we just gave our second annual Healthcare Excellence Award to the
Dana-Farber Cancer Institute for their work engaging patients and families
directly in care. So we’re very proud of that.
Building on that, I think, for the past 10 years or so, Blue Cross Blue
Shield has been engaged with our providers in conversations and iterative
incentive programs and measurement programs around quality and safety.
At this point, just very close to 100 percent of our provider network is
involved in some kind of quality-based incentive program, and we just, in fact,
added skilled nursing facilities to that by asking our skilled-nursing
facilities to attend a forum on medication safety.
We’ve also embarked on a multifaceted approach to kind of our contribution
to quality chasm crossing, including payment reform, which we think is
essential, performance measurement and reporting and public engagement. We
think all of these activities help support the movement that we all feel needs
As an example of the continuum that we’ve been on for the last several
years, we’ve had a primary-care incentive program for a number of years, and
since 2001, this has really created a significant amount of added income
potential for our physicians.
Sadly or the reality is that healthcare is an industry in our country, and
it is payment based, and we have found that incentive payments are one way to
engage practitioners around the kinds of activities that we want to encourage.
So this program has substantially increased the income potential for
individual physicians and represents up to about 10 to 15 percent of what they
can earn from us in a year.
The measures that we have focused on change every year but are related to
clinical process, to e-health adoption or system development.
We’ve had support for registry use in our program for a number of years.
Those registries ranged anything from, literally, a shoebox to electronic
registries, but were intended to engage providers around looking at their
practice as a population rather than individuals seeking care one at a time.
That’s a huge change for most practicing physicians, because they get paid
one at a time. And so making that link is a challenge.
We’ve also focused on generic prescribing rates. We’ve long focused on
HEDIS and HEDIS-like measures. I say HEDIS-like because we have one diabetes
measure where we ask providers to get two A1Cs a year rather than one, since
that’s generally accepted as the clinical guideline. It’s fascinating how much
discussion that engenders.
And new this year we’ve started to look at clinical-outcomes data, having
providers actually look at their own outcomes data for their diabetic or
hypertensive patients and providing us with their most recent A1C and LDL.
That’s also been a very interesting new process for us.
But the important thing, I think, about the incentive program is that it
gave us the chance to begin to engage with providers around measurement —
quality measurement, and we felt a shift in the focus of our discussions away
from, “Why do you have to measure me?” to, “How are you going to
measure me?” and, “Do I have a chance to succeed with those measures,
and do they make sense?”
So flowing out of that, we have adopted a set of guiding principles around
how we will use measurement in our incentive programs and with our providers.
This was really a formalization of many ideas that we’ve had for a long
time, but hadn’t kind of written down and said, “This is what we believe
And with the addition of Dana Gelb Saffron(ph) — who many of you know is a
national researcher in patient experience in relation to outcomes — to our
staff this past year-and-a-half ago, we did kind of formalize these principles.
And, as you can see, they really speak to the use of measurement. What are
reasonable measures? They should be nationally accepted. They should be vetted.
They should be valid at the level of reporting that you’re creating.
Providers should have a chance to see their data, understand what it means,
tell us if we’ve made a mistake, and that if we’re using data for what we call
“high-stakes use” — public reporting, pay-for-performance, et cetera
— that, in particular, measures need to follow these particular principles.
We do often enter into individual agreements with providers around things
that are somewhat less standard. Those are generally mutually agreed upon
because we want to learn something or they want to learn something or we want
to see how feasible is this type of measurement or will it enhance care in some
I think one of the reasons this is so important — and I will probably be
the tenth person to say this in the last two days, but primary care is in
peril, in case we haven’t noticed.
As a family physician, I have watched my colleagues and I struggle with how
do we provide the kind of care we were trained to provide, that we get up every
day feeling like that’s what we should be doing and feeling like there’s all
kinds of constraints and challenges in our ability to do that.
Certainly, fewer doctors are choosing primary care, partly due to economic
reasons. Their income potential is not as great as it is for specialists.
Medical students can all tell you about the road to success, and I actually had
a medical student say that to me last week. I was shocked.
In case you don’t know what that is it’s radiology, ophthalmology or
orthopedics, take your choice, anesthesiology or dermatology. And they know
this before they start their third year of medical school. So we’re up against
some pretty big odds here.
And the fee-for-service system that we are all saddled with doesn’t reward
the kinds of activities and care provision that we want to see. It provides
volume over quality and reliability, and that’s a big problem.
Coupled with that, we have increased demands from externally, certainly,
the national movement towards increased measurement, improved safety and
reliability of care, transparency, expensive infrastructure investments that
practices need to make. It’s a big challenge.
From the payer’s perspective, we add another challenge, and that is the
economic perspective. The numbers you’ve seen before, healthcare expenditures
rising steadily. We’ve had over double-digit rate increases in our market for
the last six years with no particular end in sight. There’s no reason to
believe they wouldn’t continue, at a time when wages for workers are stagnant
or falling, and that’s even before all the crisis that we’re in now.
Add to that that we do now have healthcare reform in Massachusetts where
individuals may be buying insurance for the first time and where small
employers are now purchasing insurance for the first time. It’s awfully hard to
explain to these people that are buying care why their care is going up so much
every year and what can we do to help stop that.
It’s also hard to explain to primary-care physicians, who are trying to
make improvements, that we just don’t have any more money. There is no more
money. We have to find a way to redistribute the money we have to get the kind
of care that we are looking for.
I’m still a firm believer in the quality-equals-affordability mantra. I
just — it doesn’t make sense any other way to me, and so we are firm believers
that if we can support an organization of care that provides more reliable,
safer, less redundant, more coordinated care — all those wonderful words —
that it should cost us less.
But simply paying physicians more isn’t the answer. The pool isn’t getting
any bigger, and, frankly, a modest pay rise will make you happy for a short
period of time, but if you’re still working in a nightmare, it’s not going to
make you happy for long. I think it’s just reality.
So as an intermediary between the real payers, the people buying the
insurance and paying the bills, and the delivery system, health plans really
are in the position of explaining these expenditures to others.
One of the things that we’re really looking at is how can we radically
change the payment system. And I’m not going to spend a huge amount of time on
this, but this is an important backdrop to the rest of what we’re talking
RCEO has challenged us to create a new kind of arrangement with people.
Some people say it’s an old kind of arrangement — “Ah, that’s just
capitation.” — but when I recall capitation, it was all about the money,
and it didn’t have anything to do with the quality, and it had to do with
ratcheting down the price every year, so that you could no longer provide the
care that you were looking at.
This is very different. We’re looking to work with organizations or large
communities on really fundamentally changing how we pay for care and how they
provide care that ensures high reliability, quality and safety, that ensures
that efficiencies that those large organizations are able to create create
savings for them, not for us, so that they are incented to work on reducing
redundancies of care, and also produces more predictable and controlled
This is huge. It’s even huger than medical home, but it really requires, I
think, the kind of changes in primary care for communities to be successful. So
we are in the process now, as a company, of looking for communities or
organizations to work on this challenge together with us.
But we feel very strongly that the patient medical home is an important
stepping stone in that process. We have been working for the last 18 months or
so on developing our vision of what the patient-centered medical home will look
Thankfully, after that 18 months, during that time, the other organizations
were kind of coming up with their view, and, thankfully, they actually
converged pretty well, which I was very relieved to see.
If we had gone off in another direction, it would have been a little
frightening, but we’ve set out as our vision that when we have achieved
patient-centered medical homes, they will provide an experience of care that
patients will view that practice as the place to go for their care. They will
view that not because we tell them they have to go there, not because there’s
any contractual requirement, but because they know that’s the best way to get
the best care.
When that occurs across the board, I will be so happy, because I think that
will really mean we’ve arrived.
Among the goals that we’d like to see from patient-centered medical homes
are overall better health, and that is not just better chronic-disease
management, but better management of chronic circumstances, better interactions
with providers, better engagement of the patient, so that they feel that taking
care of their health is as important as we think it is, and that we understand
the barriers to that and can help those where we can.
We would like it to provide a better experience for both the patients and
the healthcare providers, as well as sustainable, affordable healthcare that
can be demonstrated to the people who are paying the bills.
That’s a big mouthful, and I think the piece that we’ve added to the
conversation here is that we are accountable to other people, that we have to
be able to demonstrate to the people that are buying our services, so that we
can then buy services in the provider networks, that there is value in what
There is value in what they’re providing now, but we’d like to see it go in
So how do we get there? I think, frequently — and this touches on the
discussions that we’ve had previously. I think frequently our focus is on the
things we can measure. What gets measured gets done. And the things that are
most easily measured are the under-used things. They are the
chronic-disease-management care that’s not happening. It’s the people who
aren’t getting their preventive care.
And so deficiencies of care have tended to be the focus of a lot of what
we’ve done to date. It’s been a focus in our primary-care incentive program.
Existing national measures around quality and safety are very focused on
this area at the present time. They’re easier to measure. We can look at
claims. We can look at charts. We can see what’s missing.
Unfortunately, most physician practices actually have a very hard time
seeing what’s missing, and I know from the times that I was seeing patients,
I’m much better able to tell you what was going on with the person that came
last week, but I could not tell you which of my diabetics hadn’t been in for a
year or who hadn’t had a physical. I might not even be able to tell you really
who all my diabetics are.
And I think that’s a major focus from our perspective, on what a
patient-centered medical home should be able to do, not only provide care for
the patients as they come in, but really know who you’re taking care of and
what should be done.
I think, in addition, we also need to address the overuse and the
complications and the misuse. “Misuse” is a word that’s often
misused. The IOM really means complications of care that is otherwise
reasonable to provide.
These are much harder to identify. They’re much harder to pin down, and
they’re much harder to fix, and that’s why I think we don’t measure them very
much, because we don’t quite know how to tackle them, but those are very
clearly areas that we feel need to be better identified and better addressed
with — Our assumption is and our belief is that with more coordinated care
that those should be addressed to at least some degree.
And as I said, many physicians and practices today don’t have the resources
and skill sets to actually establish, monitor and continuously improve on
population-based care. It’s not how we’re set up. It’s not how we’re paid. It’s
not how we think. And so this represents an enormous step.
I think when we talk about what it will take to get to medical homes, I
think the mind shift and the organizational shift that practices will have to
go through is just huge.
I believe it’s worth it. I believe that we can create a framework that will
at least give people a sense of where they need to start and what they might
need to look at, but work to even get to a level one, for many practices, is
going to be enormous and we have to realize that.
I think what we feel, as a payer, is that we also have to — as we redesign
payment around medical homes — is that the payment system needs to support
that work, so that it can get done, again, within that environment of not
having any real extra money, looking for ways to redistribute that money, so
that we are actually paying for what we’re looking for.
What I’d like to focus a little bit on now is the measurement aspect of our
demonstration ideas. These are still very much in draft form, which is why they
may change by the time we’re finished, but we have put together a set of
measures and linked those to the capacities that we’d like to see medical homes
be able to demonstrate as well as to the payment system.
And this is Dana Saffron’s slide, and I really love it, except the
mathematician in me says that we’re actually missing the back side and that
this should be a different shape than it is, but, anyway, I think what this
gives us is some real large-bucket measurement domains that we are looking at
for the medical home.
Patient experience is a critically important one and represents, right now,
the best way that we can actually assess coordination and communication, and
we’ll talk a little bit more about that.
We can also assess how the patients are finding what we are offering them.
Is it meeting their needs?
The floor of this pyramid really is the structure, to me. That is the
organization of the practice, how they get the work done, what kinds of systems
do they have in place to support this kind of care. And predominantly, in our
model, this is built on the medical home-certification program through NCQA.
We also have clinical performance measures that are process and outcome, as
well as cost and efficiency measures, and we’ll go through these a little bit.
I didn’t finish my slides until midnight last night, and so Matt didn’t
have them in time to get them printed, but I have sent you a PDF, so you can
make that available to people, because the next couple of slides are a little
hard to read, but you’ll have that available.
So what might this look like from a measurement perspective?
I think when we first look at those structural capabilities, we’re looking
at what is the practice’s ability to provide a different kind of access. Do
they enable patients to get in after hours and on weekends or do they have a
solution for that, whether it’s their own office or somewhere else?
What are the coordination, communication, teaching and coaching skills or
what is their capacity to provide that?
What is their capacity to actually understand their practice, their
population, what their needs are, et cetera?
And we look at these being measured primarily through both patient
experience measures, and, specifically, we have the great pleasure and honor in
Massachusetts of having actually a statewide, multi-payer patient-experience
survey, that was developed by Dr. Saffron, that we all use, and it has valid,
reliable domains of care that we can use very well in this context to
understand the patient’s experience of clinical interaction, quality,
integration of care from their perspective as well as access to care.
And then, as I mentioned earlier, the functional sort of organizational
structure we are linking, at this point, to the medical home certification
program through NCQA, which we think is a great place to start in giving
practices an idea of what they need, at least what the present knowledge
suggests that they might need.
Linking these two potential payment mechanisms, in our thinking, is that we
don’t envision the medical-home demonstration, at this point, completely
getting rid of fee-for-service at this juncture. Maybe someday that will
happen, but as long as there are PPOs, that’s actually very difficult to do,
because they are organized that way.
But patient experience would be paid for through traditional
fee-for-service as well as a prospective payment that would cover the kind of
practice infrastructure and organizational aspects that would be needed to
provide that enhanced experience, as well as a prospective payment that would
help cover the actual sort of organizational change.
Beyond that, we’re looking at the ability of practices to demonstrate to
both us, and to their members, and to the folks buying the insurance, the value
from a care perspective, and this is heavily weighted towards chronic disease
care, as I said.
I think, as a practicing physician, it does feel like that’s most of what
you do. It’s certainly not all of the care needs that your patients have, but a
good part of your day is taken up helping patients manage their chronic
And so, at this point, our process and outcome measures are focused
primarily around chronic conditions. For the most part, they are HEDIS based.
We are anticipating — we are eagerly anticipating an addition of HEDIS
measures around obesity screening and counseling for adults and children and
We include process measures around preventive care, around chronic-disease
care for diabetes, hypertension and cholesterol management and outcome measures
for diabetes, hypertension and cardiovascular disease.
And, again, we try to use national measures. We don’t try to make up our
own. We like to use the tools we have available to us.
And although the outcome measures for HEDIS are presently done at a plan
level through surveys, we would anticipate that, for medical homes, we would be
working with them to get that information using the HEDIS definitions.
And these all would be tied to quality-based incentives, enhanced from what
we have presently, but, nonetheless, linking these to incentive payments.
And then, finally, around cost utilization and efficiency, we presently
have two kinds of internal claims-based measures around that relating to
components of the expense of medical care, particularly ones that we feel
primary-care physicians can impact, and those are around generic prescribing
rates and high-cost imaging trends, compared to the rest of the network.
Ideally, we’d love to be able to also incorporate a shared savings
component around the total medical expense compared to the non-medical home,
the rest of the network, and we’re still working on that.
So what we have is a framework of practice capacities that we’d like to see
that builds off of the NCQA framework, but also includes the additional aspects
of coordination and collaboration which we’ll discuss a little bit more in a
We have measures that relate to clinical processes of care, clinical
outcomes of care and efficiency — cost efficiency of care, and then we have
payment structures, fee-for-service, prospective payment, quality-based
incentives and potential for savings as the framework around the model. Hasn’t
been finalized yet, but that’s what our thinking is at this moment.
That’s a lot. Any questions before I go on?
So this gets back to kind of what Dr. Starfield was talking about and what
Dr. Winkler was talking about.
We feel this is a great place to start and for practices to get to that
point is going to be an enormous step.
I still also worry about what I’m calling the C-cubed areas — the
collaboration, the communication, the coordination. We all know that these are
words that we use to describe good care. Who wouldn’t want to have these
Have we really identified what we mean by that and what we’re expecting
providers to be able to do, what we’re expecting patients to be able to do
around these things?
How would we know if day-to-day care is actually meeting that? And what if
the care provided meets the expectations of communication and collaboration and
coordination, but maybe isn’t the right care or patients haven’t been afforded
the chance to access the right care? So there’s — from our perspective,
there’s still some questions around this.
You know, certainly, transitions of care across the continuum, information
transfers, not only hospital to home or hospital back to doctor, but did the
specialist have the information they needed when you did send them? How would
you know that? How do we assess that? How do we do that on a routine basis, so
that we can measure that?
What about when personal or cultural beliefs change the desires that the
patients have, change their roles? What if the patients don’t want to
participate? And I know I have patients who will say to me, “I really want
you to tell me what to do?” And I struggle with that, because it’s not the
way I would like to provide their care. So how do we deal with that? How do we
measure that? How do we understand that?
So I think, speaking to what we’ve heard a little bit already, is that I
envision this process of ongoing measurement development around these three
areas, starting with, really, identifying and prioritizing what do we really
expect people to do around these things? What will that look like and can we
name it? Can we prioritize what are the most important aspects of that? Is it
transitions of care? Is it referral process? Is it collaboration with our
Then, how do we demonstrate the value of those? How do we link those to
improved health experience?
We know that patient-experience surveys do show there is a direct link
between how patients answer patient-experience surveys and their outcomes. Is
it fair? Is it complete for us to assess these things from the perspective of
the patient’s experience? Is that the full answer? Do we need to have other
things to compliment that?
We should be establishing useable and reliable measures, not just at the
big system or policy level, but at the practice level, at the plan level.
How can we look at these things systematically and track them over time?
And then how can we link those to the business IT and practice redesign aspects
that need to happen to ensure that these things are occurring on a regular
These are questions that I think have not yet been fully answered, and if
anyone has the answers, I’d love to know them, so we can incorporate it, but I
think this is an area where there’s still a lot of work yet to be done.
So here’s my little chance to make a joke. This is what happens when you
make your slides at 11 o’clock at night.
So Mrs. I’m-An-Example is a 51-year-old woman with diabetes, who comes to
the doctor episodically. She really is struggling because she’s also taking
care of her elderly mother who has a lot of other issues as well.
And in today’s healthcare environment, her care is pretty much initiated by
her, and that’s challenging, because it’s hard for her to remember when she
needs to get in. It’s hard for her to keep track of all this.
In our view, in a mature medical home, Mrs. Sample’s care is planned
together with her. It’s team based. It’s in person and asynchronous. There are
reminders sent to her proactively that she is able to receive. There’s fully
accessible data that she has and we have that can — and this “we”
I’m talking about from the practice perspective — that we can both access to
know how she’s doing and what the needs are.
In today’s world, the gaps in her care or the opportunities for additional
care are not routinely identified. We don’t have a good way of knowing who
needs what and when.
In a mature patient-centered medical home, the team and the patient
together track their needs. The team can report on that at a population level.
The patient can understand her care plan and is actively involved in deciding
what are the priorities for her.
In today’s practice, she may be very uncomfortable speaking up about her
lack of understanding or desire to change the care plan.
In the medical-home model, perhaps she has a way of actually sharing that
information with her doctor in advance of her visits using other tools that can
give a sense of how confident she is in what she wants to accomplish, what she
feels she needs help with and an option to report her progress and goals.
And then one day Mrs. Sample is referred to Dr. Heart on the basis of lab
results, and so she shows up in Dr. Heart’s office, and he has no idea why
she’s there, and she has no idea why she’s there. She has no information with
her, nothing was sent, and that results in a tremendous waste of her time, his
time and resources, in that there’s a lot of care that’s repeated at that
In the mature home, there is a system in place where the referral
specialist sends all the relevant information to Dr. Heart in advance, and
she’s able to review that and say, “You know what, I actually don’t really
need to see this patient. Here’s what you should do. And if that doesn’t work,
have her come back and see me.”
These are just maybe silly little examples, but they are ideas of what we
see are the real differences between what many practices are able to do today,
not because they want to do a bad job, but they are just overwhelmed with
what’s in front of them on a day-to-day basis.
DR. STEINWACHS: Karen, could I ask you to speed up a little bit? I want to
leave time for Jim.
DR. BOUDREAU: I’m on my last one.
DR. STEINWACHS: Okay. Great. Oh, thank you.
DR. BOUDREAU: That’s perfect. Last two.
This really just speaks to the need for not only system-level measures, but
real-time measures that practices can use to monitor their own performance and
identify the needs they have for providing the kind of care that they want to
So, finally, from the health-plan perspective, we’re very eager to be
involved with helping practices to achieve this kind of change. We recognize
that it’s complex and not going to be easy to get to, but we do believe that
this is a way of helping provide patients and healthcare professionals with a
more satisfying experience, more reliable and accessible measurement and care,
but there is still work to be done, particularly around better articulating
what kinds of measures we can use to describe the coordination piece.
So thank you.
DR. STEINWACHS: Karen, thank you very, very much. I think we ought to
proceed with Dr. Walker’s presentation and then come back for questions and
comments at the end of that.
Measuring the Performance of the PCMH (Continued)
DR. STEINWACHS: Dr. Jim Walker is the Chief Information Officer for
Geisinger Health Plan, and has broad responsibilities for their implementation
of electronic health records. And I think you do research, too.
Do you have any time left over? Thank goodness, you have time to be with
So let me let you go ahead. Thank you very much for being here.
DR. WALKER: Thank you. It’s a pleasure. I’m going to talk about some of the
ways we are monitoring, measuring the advanced medical home.
As I said earlier, if this were a different presentation, this would be
measuring transformative care process as we do medical home as a wonderful
subset of the things we’re trying to accomplish.
Geisinger, very quickly — Oh, it’s 41 clinics, not 14, 31 counties —
DR. STEINWACHS: We won’t tell on you.
DR. WALKER: — in rural Pennsylvania. We have 200,000 covered lives in a
medical plan which gives us the opportunity to experiment with things we
couldn’t otherwise. And you can see the rest of that.
When I say 100 percent inpatient and outpatient EHR, that means all notes,
all labs, all communications, everything.
One hundred thousand patients have a patient health record that I’ll talk
about more this afternoon, a little bit now.
And then our outreach EHR is a little unusual. We send, under very strict
HIPAA compliance, 500,000 patient records to regional physicians every year,
physicians that share care with a patient, because they’re a specialist to whom
a patient has been referred or because they’re a PCP or a specialist whose
patient was admitted to our hospitals.
And then we’re also building a regional health information exchange, which
is starting to help transact some of the things I’ll talk about this afternoon.
So I want to talk briefly about the patient experience, process measurement
and those other things that you can see faster than I can read them.
Just to remind us what this is about, a 77-year- old man with bad lung
disease, seven lung-disease admissions the year before, multiple PEs, due to
maybe sketchy prevention, and he’s put on the COPD protocol.
Both he and his spouse are trained to call when they have symptoms — and
I’ll talk about what that data-response center is this afternoon — and he
hasn’t had an admission in a year of advanced medical home.
Eighty-year-old, sort of the same kind of story. Had four heart-failure and
chest-pain admissions the year before. Was put on a protocol where he’s
managing himself and communicating with the case manager electronically and
hasn’t been hospitalized in the last year.
That doesn’t amount to research, of course, but it’s important to remember
what we’re after. We try.
This is a set of process targets that are in production, have been in
production for a year for our committee practice services.
There are some flaws in them that you will undoubtedly tumble to, and I’ll
talk a little bit about some of them, but these are in production in the sense
that clinic managers, service-line executives, physicians and care teams are
all held responsible in their compensation for these measures.
Just a brief note about performance goals. You will see some fairly low
performance results that are way above national benchmark.
I think it’s important to separate. Certainly, we are trying to separate
between two kinds of performance measures.
Number one is optimum, but the flu vax(ph), every patient ought to be
offered a flu vaccine, and they ought to get appropriate education to help them
make their decision. We’re very big on not being paternalistic, but we think
everyone ought to get the offer and a chance to get education if they want
And we think 100 percent should be accounted, and, certainly, we’re trying
to account for it internally is either they get vaccinated, they get a
contraindication documented or we document it. We offer them a vaccination and
an opportunity to be educated on what the benefits are.
Some interventions, like getting the Hemoglobin A1C less than seven, are
much more complex and have a lot to do with patient genetic endowment and
social supports and education and preferences, and we don’t think anybody knows
what the optimum is. It’s certainly way higher than what the present is.
And then another kind of process measure that is very important for us is
process management measures.
We are managing to thousands of process goals and outcome goals, and you
can imagine very easily if you took all of the HEDIS and — inpatient AHRQ 138
and Rand’s 439 and the ACOVE(ph), however many hundred there are of those, plus
a lot of other things like access and patient experience, it’s far too many
things to manage with registries or dashboards or any other such sort of
paper-based kind of reporting system.
So what we’re trying to do is, okay, at this level how are we going to
identify the processes that are way off the rails, that need to be fixed
yesterday? How are we going to identify the ones that need first attention? And
how are we going to identify the ones that may not be perfect, but they’re
third in line to be fixed?
And so what the tool looks like is something like this — and I apologize
that it’s hard to read, but it is just what it is — so that for each one of
those measures — they could be outcome measures, process measures, access, all
different kinds of measures, pure administrative measures.
There’s an established target, and the report sorts automatically, based on
how urgent or how off-track the process is, and that second column on whether
it’s getting better or staying the same or getting worse.
So that this is developmental, but it will come to the point that the CEO
can start at the top and identify facilities that are in trouble, all the way
down to being able to identify a care team that’s having trouble and what
specific processes they’re having trouble with.
Here’s access. One of the things we track very hard is things like time to
third(ph) next available appointment and other measures like that.
Quality has a whole set of measures.
And, by the way, you’re going to say, “Well, how’d you pick
these?” Barbara’s going to say, “How on earth did you pick
Two ways. Opportunistically, we can make an internal case for things for
which there is an external regulatory case or an external payment case. And so
we’re starting with the things that we can either get paid for or we’re going
to get dinged for.
Fortunately, most of those are reasonably evidence based, and, at least as
a start, they’re fine. We assume that we’re going to have to perform to far
more than these, but if we can learn how to do this, then it’s relatively easy
for us to extend what we’re doing.
You can see the complete bundle for diabetes. That looks horrible, that 2.4
percent, if you can believe that. That’s above national benchmark. In 18
months, it’s improved to 10.9, and you can see the other performance
So this is that bundle, patients getting all nine of those quality
processes performed for them or at least offered to them and we documented they
didn’t want it over — what is that? — a year-and-a-half.
Looked at differently, this is a slide that shows you how many patients are
getting none of those measures, the zero, all the way over to the ones that are
getting all measures, which should be a nine.
And you can see when we started, there were a lot of people doing
reasonably well getting five or six or seven, almost none getting nine, and
eight dropped off.
Over time — and this is three-month intervals — you can see a move of
that curve with more and more patients getting more and more of those measures
performed for them.
And, of course, if you’re a clinician, you can understand that the things
like the pneumo vaccine, the flu vaccine, the eye exam and the foot exam, we
get fairly good performance on, up in the 90s. Things like Hemoglobin A1C less
than seven, and blood pressure, less than 140/90 are much more resistant to
Same thing for coronary disease, and same kind of tracking.
We do this for — 1, 2, 3, 4, 5 in production and we have some — actually,
two acute care also in production, and there are probably about 15 in
As I said, once you’ve done one of these — The hard part is getting
organizational agreement on what the standards are even going to be and what
the targets are going to be, and once you’ve done that and built the technology
for a couple of these, first, the big thing that happens is the organization
gets used to thinking in terms, “OK. What’s the next one we’re going to
do? And who are the people who need to get together and decide how to do
So this is Adult Preventive Care. This is new. This is November 2007 to
March of this year, so four months. Not much movement. The obesity screening,
we built an electronic tool that reminds nurses, and so that gets done at a
nursing level of quality, which is very high.
This is the PGP data. So here you can see that — the PGP had much lower
standards than we do — than our internal standards. So they said a Hemoglobin
A1C greater than nine is a problem. Ours is seven. The difference between that
is seven means superb control and nine means just barely controlled, if you
could call it controlled. So against those measures, we also bench up
This is med reconciliation. This is a report that goes to all clinic
managers and to individual clinicians on their rates of med reconciliation.
Both the nurses and the doctors have a tool to document reconciliation of the
med list at every list.
You see all of these are 100 percent. That’s a little deceptive. The
average is only 94 percent. I just took a picture of the top of the list.
Very interesting. When we put this tool into the EHR, there’s just two
buttons you click to say, “I’ve done this.”
It was the first time in our history that we’ve had lots of docs call up —
or actually they sent emails — and said, “You have to put a reminder on
that. You have to put a soft stop on that, because I keep closing the encounter
before I remember to click those buttons, and I want to get credit for those
That’s the tipping point between — as you were saying, “What do you
mean you’re going to measure me?” and saying, “OK. Well, now, I
expect you to give me really good tools, so that I can get 100 percent.”
One of the good things about doctors is anything less than 100 percent is
grounds for suicide. This is the same thing by provider.
This is another measure that our insurance company has developed, a set of
quality metrics around care, service, value. Coordination is part of patient
service, I guess, clinical care. I’m not sure which one.
This is reported for all of our 4,700 impaneled physicians. This is just
our own internal performance against those nine quality measures that are
intended to be probably some very bad approximation of Barbara’s view of what
primary care should look like.
And as you can see from 2005 to 2007, we’ve had a remarkable increase in
the number of practices who qualify for this rating.
And then this is just what the report looks like that would go out to
individual practices, both inside and outside of our system.
Something that is new and — well, you’ll see some of the tools for it, but
we don’t have data yet — is managing transitions of care, so that when a
patient is discharged from inpatient ED or a nursing facility, first of all, we
make sure we get that information, but then are starting to measure physician
follow-ups, care-manager follow-ups — for high-risk patients, care managers
are responsible to follow up within 24 hours of discharge — and phone
follow-ups of patients, and then those other things that you can see.
Efficiency. This is cost trend for primary-care physicians per member per
month. This is one of the advantages of having an insurance company. About 30
percent of our clinic business comes from the insurance company. About 70
percent of ours is fee-for-service, and we represent about 20 percent of the
insurance company’s total business. So we have about 800 docs. There are about
5,000 docs in the region, so that we can actually bench our internal
performance against non-Geisinger performance using the same set of metrics.
And their costs are going up two percent — this is over a year — up two
percent. Ours are down six percent.
And, again, “medical home” is a little misnomer. It’s this real
effort to create end-to-end processes that work for patients.
Decreased acute admissions. You can see — Sorry about the stupid scales on
this. I can’t manage PowerPoint — but 15- to 20-percent decreases in acute
admissions, the same sort of range, 16 to 18 percent, of decreased
On the inpatient side — on the acute side, I don’t have it, I don’t think,
in this slide set, but when we started doing CABG, we identified 41 processes
that are evidence-based to prevent complications when you have an open-heart
We’re performing at about 95 percent on those 41 processes for all of our
patients we do elective cabbages on, and their readmission rate — 30-day
readmission rate — it’s early and the data is small, but it’s about 20-percent
reduction in readmission rates on cabbages.
This is for the patient’s health record. This gives the patient a view of
their own electronic record, so they see the same med list that the doctor
sees, the same problem list.
They click buttons to get their meds renewal. Click the buttons of the meds
they want and hit the submit button. It comes to us electronically, and we send
to the pharmacy electronically and tell the patient it’s been done.
They have secure e-messaging. So I can say to a patient, “Let’s
increase the — a couple of blood pressures next week and we’ll see how we
And so this is the dashboard that we use to manage what is the turnaround
time on those patient emails.
You can’t see it, but down there at the very bottom, is the no-show from
direct scheduling. Patients can schedule their own appointments now
electronically, and the no-show rate on that is 2.1 percent. The no-show rate
when we schedule them is five percent. So there’s a whole set of metrics that
we use to manage how that’s going. Eighty-one percent of patient messages are
One of the things we train our physicians is that it may well be the case
that the appropriate response to an email message is a phone call, because it’s
a more complex communication or that the patient should just be invited to come
in for an appointment, for a talk, because it’s that complex. We avoid about
150 phone calls per clinic per month, and I told you the no-show rate.
Financially, we’re not doing so red hot. This is unbelievably difficult and
I would say the estimates you heard this morning are way under-estimates. And I
would say that almost nobody is telling you the truth about how hard this is,
in terms of process change, in terms of organizational change, in terms of
changing the way everybody in our place works — the front desk, the nurse, the
call center, managers, everybody.
But you could see we would have — our net actual improvement was — well,
considerable. We didn’t make the fund sharing either time on PGP.
Now, there are a number of reasons for that. One, I’d say is because we
don’t have our processes down yet, and we are in the process of needing to map
every significant process we have, ream it out, simplify it, streamline it, and
then get most of it managed by electronic systems. We’re very early in that
I don’t think you’re going to see significant cost reductions, even per
unit of service given, until organizations get that kind of business process
management as part of their portfolio of organizational skills.
Process control. We map all kinds of things. Open encounters greater than
what’s at 30 days.
This one is results that have not been marked as read by a physician after
30 days. And all of these things trigger reports that go automatically.
Actually, part of the benefit of information technology is once you set
these reports up, they just go automatically to the appropriate supervisor,
and, of course, the miscreant.
But what we are still working on is having automated systems that manage
all of that also, so that we know what report has gone out and been acted on
and what report has gone out and is still sitting on the supervisor’s desk.
Supervisors are not inhuman either.
So that’s a quick view of the sort of things that we’re doing to try to
measure, what I think could be reasonably called medical-home kinds of things.
DR. STEINWACHS: Jim, thank you very, very much.
Let’s open it up for questions and comments. This is exciting from both of
DR. CARR: Really, both presentations were fantastic, as all the
presentations have been these last two days. We’ve been talking a lot about it.
Actually, I wanted to just pick up on what you were just saying about the
— or what I think you were saying about work-flow redesign, that to leverage
the electronic health record that you spend a lot of time designing the
process. Was I understanding what you were saying correctly?
DR. WALKER: Yes, when we went live with outpatient clinics, we spent two
months in each clinic. They had a control team — doctor, nurse, front desk,
anybody else that was relevant, chemo nurse, if it was — and we mapped — we
just watched them and mapped all of their processes.
And, weekly, we would feed back the process maps to this control team, and
we said, “Well, it looks to us like when the patient comes in you do this
and this and this and this, and you hand this and this off.”
And they would look at it and say, “What do you mean? We don’t do
that.” And someone else would say, “Yes, we do.” “No, we
don’t.” “Oh, we do?”
No one could remember why they did it anymore.
So we took 33 percent of process steps out of processes when we went live
with the EHR.
It’s an enormous expenditure. We customized every preference list, so that
if I type a MOX(ph) — I’m an internist. If I type a MOX, I get adult doses.
Pediatrician types a MOX, they get pediatric doses. Family practitioner types a
MOX, they get both. Well, that takes a lot of work.
A lot of organizations put this stuff in and they give the same tool to a
neurosurgeon that they give to a primary-care physician. Big-name places that
you wouldn’t believe if I told you the names.
DR. BOUDREAU: Yes, we would.
DR. WALKER: And so there’s an enormous amount of work —
DR. BOUDREAU: Just gotta say, yes, we would.
DR. WALKER: — just up front in really customizing this to the way people
Then what we found — to our surprise, to be frank — is that once this
happens, first of all, you’ve got all these people across the organization that
are now process reengineers. I mean, they’ve actually thought about, “Oh,
my God. You could fix this. I could quit doing this stupid thing that I don’t
even know why I’m doing it.”
And so we actually — It took us a while to tumble(ph) to it, but we now
have optimization teams that are scheduled regularly to go back into clinics
and say, “OK. Now that you’re — “ we’ve been — most of us five-10
years. “You know, what are the next things that you want to improve? What
are the — You know, how are we going to do care coordination? How are we going
to link the care manager to the notes? How are we going to do whatever it is?
How are we going to — “
One of the things we did, we said, “Well, look, why do we depend on
the doctor to remember to ask the patient if they’ve had a flu shot, if the
patient comes into the office anyway?” Or, slightly less stupid, “Why
do we expect the nurse to?
“Why don’t we just run the database and say, ‘OK. We’re going to
send this carefully-written letter to all 22,000 high-risk patients, and then
all of everybody else, and say, “If you want a flu shot, these are the
reasons why it’s a good idea. If you want one, call this number. They’ll
schedule you. Come in, get your shot and go home.”’
We increased our flu-shot rate, which was already above national benchmark,
20 percent the first year we did that.
And so what happens is all across the organization, we have more
high-quality process-improvement ideas from doctors than we can execute. We
have 140 people who do nothing except work on the EHR.
DR. CARR: That’s great. I think this is a very important piece of this
because it is the redesign.
I mean, we’ve been — I’ve been jotting some notes down now for what I’m
supposed to say at the end of the day, but I think one of the things that is
happening is that we remember a certain kind of healthcare, and we’re trying to
— when we had a PCP that saw you at home, saw you in the office, saw you in
the hospital, and your family was home and nobody worked and relatives were
there to help you.
And I think we’re thinking about that and trying to fit it into
contemporary environment, and I think that this redesign — We’re in a
different world now and there are different processes at play.
Just one other question, if I may. We’ve talked a lot about registries, and
I’m wondering are these derived from problem lists?
DR. WALKER: We derived them from all sorts of things. There are actually
fairly sophisticated algorithms that you can use, so that — Chronic kidney
disease is an example.
We just ran the database for everybody with kidney function — that means
they have chronic kidney disease, and found that of — I’m going to get the
numbers a little wrong, but 15,000-ish. There were 3,000 who hadn’t been seen
in the last year.
And so, there again, once you get this going, we had generalists and the
kidney people sit down and say, “OK. This is what optimized care of
chronic kidney disease would mean. This is what the primary-care docs would do.
This is what the specialists would do. This is what the referral would look
like. This is what the care plans would be,” and put that all into
production and invited those 3,000 patients to come be seen, make sure that all
the patients with kidney function at this level are less have been seen by a
kidney doctor at least once and have a care plan that they’ve contributed to
and that whole sort of thing. Yes. So that becomes the routine way we work.
And so that’s why even primary-care, for us, is just a subset of the
characteristics of a good healthcare system, not the whole game. Because what
we want — and we’re just starting to execute this.
If you come to us for an elective total knee and you’re just going to see
an orthopod who would care less in the world about pneumo vax or flu vax or
anything else, your mammogram or anything, we are going to have a system where
we will assess your risks, your needs for all those other things, and if you’re
being taken care of somewhere else, hallelujah, and we don’t say anything to
If you’re not, we’ll offer you either an opportunity for one of our people
to take care of you or for us to communicate with your primary-care doc with a
set of things that they may want to consider for you.
So we are seriously trying to make these processes run end to end. Wherever
you hit the system, we feel it is our responsibility to get all your stuff
done, and to do it as dis-intermediated, as electronic, as remote as you want
to make it.
Now, if you want to come in and have your hand held and be told what to do,
we will schedule it, and we will hold your hand and tell you what to do. The
patient has a right to tell us to tell them what to do, too.
But if you’re one of the people who says, “I don’t want to be in your
parking lot,” then we can do most of what we do without you ever being in
our parking lot.
DR. STEINWACHS: Karen, I think you had a comment, and then Paul Tang.
DR. BOUDREAU: Yes, I wanted to add two things to that. I think, in
particular, the question about the registry and building it off of problem
lists, I think one of the things that makes me very frustrated as a plan person
is how many of the practices that we work with that do have registries, but
they’re built off of our problem list for our HMO patients.
And that says to me that you’ve got a system of care for the people that
you get the data on from someone else, and then you have something else for
everyone else, and that worries me greatly.
And I frequently remind practices that just about everybody is doing
electronic billing now, and that means you have a source for creating your own
registry. Because your diagnosis codes are in there, you have the ability to
create your own lists of patients that may need things.
And I think, echoing what you were just talking about with what I always
called in-reach, is that a lot of practices worry that if they expend access,
if they kind of provide more asynchronous care, if they’re not having patients
come into the office that they won’t have enough to do, recognizing that
they’re a long way off from that.
But I think the capacity of the electronic systems to really get to the
things that nobody can remember to do and to identify those patients who have
needs that are not being addressed in any way, and giving them the opportunity
to have those addressed is critically important.
DR. STEINWACHS: Paul.
DR. TANG: I have three questions, please.
DR. STEINWACHS: Is this going to be in a super-efficient way?
DR. TANG: Hopefully. Really impressive reports, Jim, as far as what you
show to your docs, and I think we have the same experience in terms of you show
them the reports and it works. So I have three.
One is a question I always get asked about, “Well, you’re in Silicon
Valley.” Well, you’re in rural Pennsylvania. I always use you as the rural
Do you think there’s much of a difference in terms — You said, “We
try to do things remotely. We — “ What’s your take on rural Pennsylvania
versus Silicon Valley?
DR. WALKER: It’s interesting. I’m sure our internet access isn’t as high as
Silicon Valley, but it’s as high as national average.
There are good studies that show — There’s a guy at Wisconsin did the
Chess(ph) study. There are good studies that show that if you do electronic
systems right, including electronic remote-care systems, you advantage
low-literacy people, low-education people more than you advantage
Now, obviously, those people benefit, but there are a lot of advantages to
remote care to asynchronate.
One of our grandmothers with a sixth-grade education, if she can do it at
home on the patient health record, her niece can help her understand the
questions and fill out the questionnaire, and her 60-year-old daughter, as you
know, can help keep track of appointments and med lists and when renewals are
needed, so that while we’re not trying to force anyone, we don’t see a big
And when we do feedback groups, we find that there’s lots and lots of 75-
and 80-year-olds who love the patient health record.
We have an 82-year-old who sent me an email — sent us an email — and she
said, “I was in Maine and I got sick and I ended up in the emergency room,
and I could open up my medical record to them.”
All she needed was an internet-capable computer, and she knows her ID and
password, showed them her med list, her problem list, her recent lab results,
her allergies, and she said they were in hysterics. (Laughter).
She said that they told her that they didn’t have to do tests that they
would have done otherwise and were able to take care of her better and faster
because she had that.
So that, no, I don’t think that’s the divide. I think it’s more about being
in a system where it really is a value and it’s easy to use and natural to use.
DR. TANG: So these questions get harder as I go on. (Laughter).
DR. STEINWACHS: This is a three-level process, and you’ll be scored, Jim.
DR. TANG: That’s right. So far, so good.
The next one is getting the doc buy-in to what you’re trying to measure, and
there’s the external reporting, external reward measures, which are mainly
based on claims data, and then there’s the what the doc’s been taught or beat
in their heads as far as complying with clinical guidelines.
One of the ones you touched on is the whole A1C control. We weren’t taught
to manage down for how bad you are, not be bad, but you’re taught to manage
what percent are you complying with guidelines. It’s seven percent versus the
over nine percent.
I know we spent a lot of time trying to devise our own measures to fit the
guideline and physician frame of reference versus just using — and so we have,
actually, a separate parallel additional expense to go comply with the
How did you deal with that problem or how did you address that problem?
DR. WALKER: Perhaps simplistically.
For the most part, the internal goals that we have for ourselves are more
stringent than the external goals. So we use the external goals as prods to our
vendor and as justification in terms of internal business case.
But we intend to be so far ahead of them that they’re fundamentally
irrelevant to us.
DR. TANG: Okay. Third.
DR. STEINWACH: Counting.
DR. TANG: So one of the set of measures used in diabetes — there were
something like nine, and one of them was frequency of getting A1C, and I think
you mentioned like the twice a year versus once a year.
So I saw you scored the same thing we did on the frequency of A1C, which is
97 percent, which is almost humanly impossible, as we would recognize, and the
reason is because the administratively-defined diabetic is self-perpetuating
and saying it’s only the people who you think are diabetic and working on
versus your total diabetes population, which is gleaned either from a registry
or problem list, more accurately.
And how do you — So just to take our case, if you look at the folks that
were missed by the administratively-defined diabetic, then it would only score
68 percent and the truth was somewhere in the middle; i.e., 78 percent versus
Now, the difference in how you recognize, reward, pat on the back or
counsel is very different, and how do you deal with that difference?
DR. WALKER: Diabetes is a good example.
The way we define a diabetic is either it’s been on an encounter problem
list or it’s on the patient’s problem list or there’s a lab result that is
consistent with diabetes, and I think we look at some pregnancy outcomes and
sort of — So that’s our definition. I mean, we just have a Geisinger
definition of how we identify a diabetic, and we regard that as — standard.
DR. TANG: So that wouldn’t be the 97 percent, though, because that is used
— Presumably the standard definition is —
DR. WALKER: No, so the 97 percent is 97 percent of all of those people. For
us, it’s about 22,000 people that one way or another fit the definition — And
you’re right. We may still be missing people.
But it is keyed to like hospital glucose results. So that any woman that’s
been pregnant, anybody that’s been in a hospital, we’re probably going to
catch, and have to be someone that’s just way outside the system.
DR. STEINWACHS: Harry, and then Larry. I had Harry, then Larry.
MR. REYNOLDS: No, Larry’s probably got a better question. You go first.
DR. GREEN: Defer to the senator from North Carolina.
MR. REYNOLDS: There’s a troubling side to these two presentations.
Excellent, outstanding results, everything else, but I keep hearing that you
had to deal individually with each provider, each doctor, each process, each
And one of the things we do as a committee is try to put together some
national standards, some other things that move things forward.
So, at the same time, right now, as an implementer back home, I’m putting
in NPI, where we’re playing hand-to-hand combat with every doctor in every site
for every reason, to come up with a number and trying to roll it out, and it’s
a requirement and so on.
But just listening to the discussion between you and Paul, and the earlier
discussion from Massachusetts, we’re only deciding one procedure and one doctor
at a time, which sounds like forever — excuse me, sounds like never.
DR. WALKER: I don’t think —
MR. REYNOLDS: Yes, but in one place, with 120 people working on the EHR and
if you — No, and, again, yes, the results are spectacular, but as we try to
make this —
So why couldn’t we take — why aren’t things — when we talk about
standards for EHRs and other things —
DR. WALKER: I don’t think it’s about EHR.
When you go to buy a car, you would not buy a car that didn’t have a
computer in it — probably several. I don’t know. Would you? Because they
couldn’t make a car that you would find acceptable —
DR. TANG(?): He’s from North Carolina. (Laughter).
DR. WALKER: But —
DR. STEINWACHS: Horse and buggy.
MR. REYNOLDS: I think you could find out there are computers — I love this
DR. WALKER: If we can get the incentives right, so that people are actually
rewarded for achieving these things, then what you will have is not five-person
practices going out to buy an EHR.
What would they want with an EHR? Then they’ve got all the process
problems. They’ve got all the maintenance problems. They’ve got all the update
problems. They’ve got every time you change the goals that we have to meet,
who’s going to put them in for them?
What they’re going to want to buy is a set of processes, and they’re going
to say, “You come in. You teach my nurse what to do. You teach me what to
do, and you produce a report out the back end that says I’m 100 percent on flu
vax, pneumo vax, mammogram and 1,000 other things, and you tell me the
They are business people. They can count, and I think that’s when this
changes, not going doctor to doctor trying to say, “Do you want to change
everything about your life just because we don’t have anything else to do
MR. REYNOLDS: No, I think that’s great because a lot of the solutions are
being led by technology, not process and not structure. So thank you. Good
answer. Thank you.
DR. GREEN: I’d like to raise a totally different issue and ask you what
you’re doing about this.
There’s another transformative change in the certification processes of
professionals, particularly physicians, but it’s also coming in nursing and
pharmacy and all professions. The code word for it in medicine at the moment is
maintenance of certification.
The idea here is that answering the right multiple-choice question once in
your life does not qualify you to be a practicing physician forever and that
what really matters is what you do for patients.
And so the American Board of Medical Specialties — all the medical
specialties — are on board with this idea of maintenance certification.
That process includes what’s called a Part 4, which means that you need to
do some of the things that both of you showed in your charts and your tables
and your organizations, that you actually need to ask and answer a question
about your practice, you need to measure something, you need to try to fix
something, you need to do some personalized reengineering.
How are you and your organizations connecting up the maintenance of
DR. BOUDREAU: That’s a great question, and it’s something that we’re
struggling with on a number of fronts.
One of the things that we have entertained is how does that fit into our
credentialing process, particularly for physicians who aren’t practicing at the
You know, many health plans rely on hospital credentialing processes for
some of the quality oversight of individual physicians. As that goes away,
maintenance of certification may become a very important piece of that
particular part of quality.
Our plan is not, at present, but there are Blues plans today that recognize
maintenance of certification activities in their incentive programs for
individual physicians, and I know Highmark in Pennsylvania does and some of the
other plans do as well.
And that is something that we have thought about particularly for
physicians who may not have sufficient numbers to be measured under some of our
That last piece remains a very significant issue. And one of the things I
hope for medical homes is that they will also perhaps provide a structure where
unrelated physicians may choose to come together if for no other reason than to
share their measurements together, so that their numbers can be big enough to
count. That’s a separate question.
So there certainly are possibilities for including maintenance of
certification activities in incentive programs.
I also think that those activities can be part and parcel of the
improvements that need to happen as you develop your medical home, so that the
work that you do to become certified or the improvement work that you do along
the way within your medical home would certainly have the potential to qualify
for maintenance of certification activities.
DR. WALKER: We’ve had introductory discussions with some of the
certification boards to talk about how they would define the activities and to
see if we can execute them in our system, which, you know, fundamentally, we’re
doing those things. It would just be a matter of them defining what exactly
measuring your performance means.
I mean, does it mean that you get a report like this and you go to a
micro-team meeting and discuss how to improve it and change a process? If so,
we do that all the time.
It’s really a question of how they end up defining what those activities
would look like.
DR. STEINWACHS: I’ll let Paul have one short question, but then we need to
break for lunch, because there is a human need here that goes with a
healthcare-improvement need and —
MS. GREENBERG: Well, also, we have people coming at one.
DR. STEINWACHS: Yes. Paul.
DR. TANG: Yes. Unfortunately, this may be the hardest bonus question, and
it has so much to do with measurement or perceived measurement, and it goes to
your point, Jim, about the — “Why don’t you give me an alert to tell me
to push the button?”
Knowing your work on EHR safety, clearly, there are times when it is easier
to push a button than to actually do the task, and that’s obviously one of the
things you have to consider when we actually design the measures. Thoughts on
DR. WALKER: Fundamentally, we regard that as first phase. It’s better to
check the button than not to.
Most people, there’s enough cognitive dissonance when you check a button to
say you’ve done something you haven’t that it probably increases the odds that
you’ll do it.
Anecdotally, it’s pretty clear people are doing, but, fundamentally, we’re
trying to offload that out of the office visit, basically, so that the patient
will have an opportunity, either at home before they come in, or at a kiosk
when they check in, if they want to, or face to face, if that’s the way they
prefer to do it, they’ll have the opportunity to go over their med list.
As you know, I mean, it’s routine for a patient to go home and say,
“Oh, heck. I forgot to tell him about the so-and-so Dr. So-and-So started
So what we’re trying to do is just make that one of those things that we
make more remote, more virtual.
And that’s actually a theme across a lot of this is that what we’re trying
to do, fundamentally, is change the way we follow up lots of these things, and
so more and more things we’ll be able to say we can confirm that this actually
happened, because, “Here’s the message that went to the patient,” or,
“Here’s the this,” or, “Here’s the whatever.”
Again, that’s one of the things you need big-time information systems for,
because that’s thousands of data points that we’re going to have to be able to
collect and report on, and more, as time goes on.
DR. STEINWACHS: Well, I want to thank both of you. Karen, Jim, it’s been
(Whereupon, a luncheon recess was taken at 12:21 p.m.)
A F T E R N O O N S E S S I O N (1:02 p.m.)
DR. STEINWACHS: Well, I want to welcome everyone back, and thank you for
rushing your lunch and bringing it back, so that we could stay on schedule.
DR. STEINWACHS: This next session is an opportunity to look at our national
health information systems, some of them, and to try and begin to answer that
question of to what extent can we use health data in the U.S. to measure the
extent to which medical homes exist or the characteristics associated with them
exist, and some of the things we’ve been talking about. And we’re very
fortunate to have three people with us who are going to help us go through
I thought we might proceed in the order listed, and Dr. Doris Lefkowitz,
who is with the Center for Financing, Access and Cost Trends and AHRQ, and I
assume Doris is going to be talking about MEPS.
And Dr. Stephen Blumberg who is at CDC and part of the Health Interview
Survey Group and can answer another part of that question, but also links to
MEPS, too, because MEPS uses the Health Interview Survey.
And I guess, Steve, you’re going to do more than just the Health Interview
Survey or —
DR. BLUMBERG: Really, I’m not going to talk much about the Health Interview
Survey at all. It’ll be more to the National Survey of Children with Special —
DR. STEINWACHS: Okay. Well, it’s a good thing I asked you. Matt knew, and
he’s given me a lot of information. I had data overload and — you know. So
Paul Tang is going to help me, one day, get an internal system working.
And it’s a great pleasure also to have Dr. Catharine Burt, who is also at
the National Center for Health Statistics, and, Catharine, you’re going to be
talking about —
DR. BURT: I’m going to be talking about the ambulatory-care surveys of the
National Health Care —
DR. STEINWACHS: OK. You can see that I didn’t have my cheat sheet in front
of me, and I apologize, but I thank you all.
DR. BURT: I can talk about something else, if you’d rather.
DR. STEINWACHS: Well, actually, with my state of knowledge, as you can see,
you could pick anything and I’d say yes. “Hey, Catharine, that’s
One of the things I think we were hoping would come out of this set of
hearings was not only a better understanding of to what extent are there common
definitions and common ways to measure the medical home, and we’re
understanding that there are many varieties of medical homes, but there are
some consistent themes and visions there, but also to be able to come back and
make that assessment of the capacity of our current national health statistics
data capture to get at some of the dimensions and attributes of medical homes.
And so, Doris, would you like to lead off?
DR. LEFKOWITZ: Sure.
We were just talking — and I came to the conclusion, after listening to
the morning hearings, that my dog has a medical home, but I don’t. (Laughter).
DR. STEINWACHS: How’s your dog’s insurance coverage?
DR. LEFKOWITZ: It’s all self-pay, remarkably.
DR. STEINWACHS: Now, you may understand the basic model.
DR. LEFKOWITZ: Now, I know why.
But, you know, I get electronic reminders for all my dog’s appointments. I
get electronic reminders once a month to give her her flea and tick medication,
and I got to choose the day that I wanted to get it on and did I want a
follow-up reminder if I didn’t click, did I give it to her.
When she had a medical emergency on the weekend, she went to the emergency
provider. They sent all of her records, by the following morning, to her
regular vet, and all of the information is shared with the place she boards.
DR. STEINWACHS: Would your vet be interested in taking some human animals
into the practice?
DR. LEFKOWITZ: Gets better care than I do.
OK. So I’m here to talk about the AHRQ data resources for the
patient-centered medical home.
What I’d like to do is give you an overview of AHRQ, talk about several
data resources that AHRQ has for looking at the patient-centered medical home,
spend most of my time talking about the Medical Expenditure Panel Survey, and
also give you a few caveats about the implementation of new measures in
I think there, the few things I’ll talk about will be similar things that
my other federal colleagues would like you to know about the time trajectory
for doing anything new in a federal survey.
AHRQ, as most of you know, is the Agency for Healthcare Research and
The mission is to improve the quality, safety and effectiveness of
healthcare for all Americans.
AHRQ actually has three data resources that are relevant to looking at the
While the Hospital Cost and Utilization Project does not have full records
for a person’s medical-care experience, we do have hospital discharge records
that have been used to look at things like admissions for ambulatory-sensitive
conditions and things like that, which are certainly, at a national level, the
result of not having a medical home.
We also have the Consumer Assessment of Health Plans or the CAHPS Program.
While not a data system in itself, it’s a series of tools that cover many
of the aspects of patient-centered care that are parts of the way that many of
you are thinking about evaluating the existence of a medical home or the
performance of that medical home.
Beyond that, I think the CAHPS Program is a good model for how patient
ideas about their experiences with medical care can have basically standardized
survey tools developed and implemented.
And I think one of the gifts of the CAHPS Program is that they really
thought about, “Well, does the person actually have a clue about what
they’re telling me?”
We were joking beforehand: Can’t we just say, “Do you have a medical
And, yes, we could and people would actually answer those questions. I
mean, I’m sure people would say yes or no, but we would have no idea what it
The advantage of the CAHPS methodology is they actually try to correlate
the kinds of experiences that people report about their medical care with
outcomes that are experienced in practice.
And then MEPS, which is our last tool, and I’ll spend most of my time on
MEPS, is a large ongoing longitudinal survey of both households and medical
providers, and it captures a wide range of information that can be used to
evaluate people’s experiences with medical care.
Annually, MEP surveys about 13,000 households which translates into about
33,000 persons. It represents the civilian, non-institutionalized population.
Couple of important exclusions from that. People who are residing long term
in nursing homes are not included in the MEPS, nor are people who are in
The households are asked to participate in five interviews over 2-1/2 years
to yield two full calendar years of medical use and expense data, and we
collect our household data collection through a single household respondent
using a computer or assisted personal interview, with a self-administered
questionnaire given annually to all adults in the household.
Our core content include more demographic data than anyone could imagine,
use charges and payments for medical-care services all reported by the
household, an extensive battery of health-status measures, conditions
associated with medical events and priority conditions, employment and
We also have several supplemental forms. We have an access-to-care module
for adult and children separately. We have a battery of questions we administer
annually on whether they’ve received preventive care in accordance with various
We do ask people who have specific conditions whether they’ve received
certain recommended procedures that are associated with those conditions.
So for diabetics, we ask them whether they’ve had one Hemoglobin A1C test
in the last year. We ask them whether they had a foot exam. We ask them whether
they had a retinopathy exam.
We collect a subset of the CAHPS measures annually for all adults. There’s
about 15 measures that we collect on, and we also do other self-reported
information, adult, smoking status, their attitudes and values about
healthcare, things like that.
And we have an annual income and assets supplement.
MEPS also has a medical-provider component. We survey the specific
providers identified as sources of care by the household.
We do this to supplement the household’s medical-expenditure data that they
give us, because households are not particularly reliable reporters of how much
money actually changed hands in their medical encounters.
And we focus on payments made for medical care, particularly the kinds of
events that households are especially likely to misreport.
So households, for instance, are very good at telling you whether they went
to the hospital. It’s a salient event for most people. They don’t under-report
it or forget it, but they have no idea how much money changed hands,
particularly for the various associated physicians and ancillary services that
may not have even been on their initial hospital bill.
We also do other kinds of medical events as well, but we sub-sample those,
because households are a little bit better about telling you expenses for
physician visits and things like that.
We only get that information with the written consent of the patient and
with cooperation from the medical provider.
We have about an 85-percent permission form sign rate for households and
about a 92-percent cooperation rate from physicians and hospitals. And we don’t
Our sample includes all hospitals and associated physicians. Annually, that
means we’re collecting records out of about 4,500 hospitals, which is a
significant percent of the hospitals in the country.
All home health agencies. We get a very tiny percent of home health
agencies in the country, because it’s such a small number of people receiving
those services in any year. We get all home health agencies reported as sources
All pharmacies that the patients report that they received a medication
from and a sample of office-based physicians. What characteristics of medical
homes can you get from MEPS?
We have a usual source-of-care question, and we identify characteristics of
the specific provider at that source. We say, “Well, you tell me you go to
Joe’s clinic. Is there a special doctor that you see at Joe’s? Is that doctor
the one you see almost every time?” And then we ask them questions about
the characteristics of that medical provider.
We have a standard battery of access questions. In addition to, “Do
you have a doctor you usually go to?” we have questions about waiting time
for appointments, ease of phone access to that physician and other barriers
that you mostly haven’t touched on today, things like the accessibility of the
provider by transportation and those kinds of issues.
We collect some aspects of patient-centered care. The CAHPS questions get
at things like whether the patient believes that the doctor takes the time to
understand them and their questions, whether they’re satisfied with their care,
but it doesn’t have the full complement of experiences that you’re looking for
in the definition of medical home.
Before we started this afternoon, I was sitting here thinking, “Oh, my
gosh. This clearly is an issue that’s not going to go away, and how are we
going to get households to provide information about a medical home, since I
don’t think we can walk in and say, ‘Do you have a medical home?’”
Nor do I think we can ask, “What’s the interoperability of medical
records like at your primary-care office?”
So we’re going to have to come up with additional measures to provide some
benchmarks for measuring the penetration of medical homes into the population.
I mean, one challenge that we face in the kinds of surveys that are done in
the federal sector is we can’t customize those questions to a particular plan
Even with something as simple as implementing the CAHPS questions in a
federal survey required substantial modification, because all of those
questions talked about your experiences with the doctors at your plan.
Well, a significant percent of people are uninsured, and they don’t have a
plan at all.
Other people with insurance have providers that they go to, but may not
perceive themselves to be in a plan the same way that you perceive them to be
in a plan.
So the wording of these questions has to be very careful so that if you
want to look at the penetrance and you want to actually look at
characteristics, rather than just who’s willing to answer the question,
“Do you have a medical home or not?” we have to make sure that those
questions suit the variety of medical situations that our respondents, that
Americans are likely to find themselves in, everything from the 20 percent of
people who never go to a doctor in a given year, who don’t have any encounter
with the medical-care system — How do you want them to answer those questions?
— to somebody who goes to Dr. Brown, and Dr. Brown is the only doctor in that
office, and the entire referral system is in his head, and he may or may not
have better referral practices than somebody with a big electronic system.
So how do you want all of those varieties of situations answered in the
questions that you choose to ask in a national survey like this? It’s a
The other issue in federal surveys is that time is a precious commodity.
Questions that you want to ask of every person require more time, particularly
if it’s a household survey and you’re going to loop through several people.
And if you want this as something that can be measured every year, it also
takes more time than something that you want to administer once as a supplement
or once every couple of years.
I think we’ve already gone through the ease of administration to the
general public that, again, a measure that’s incorporated into this kind of a
survey needs to be easily understood and answered by people in a variety of
Although, there are certainly untested questions and on benchmark questions
in MEPS, we try to ensure that measures do undergo some level of testing and
some level of evaluation, particularly if they’re things that we consider
important to report out on. So it’s important that our measures be ultimately
tested and evaluated.
And that’s it.
DR. STEINWACHS: Doris, thank you very much.
Why don’t we go through all presentations and then we’ll open up for
questions and comments?
DR. BLUMBERG: Well, good afternoon.
I am Stephen Blumberg from the National Center for Health Statistics, and
I’m part of the Division of Health Interview Statistics. It is the division
that does the National Health Interview Survey.
The reason I’m not going to talk much about that here today is because the
National Health Interview Survey really provides very little in the way of
measurement for medical home.
We do have usual place for care. We do have questions that assess reasons
for delays in getting care or for unmet needs that can get at some of the
pieces of the medical home, but, really, beyond that, there’s not much.
Rather, where our division focuses its efforts on medical-home measurement
is with pediatric populations, and so I’m going to talk about the National
Survey of Children with Special Health Care Needs.
I understand that you’ve already heard a little bit about that survey
yesterday from Dr. Bethell. She gave a higher-level overview of how medical
home is measured in that survey and also across several other surveys.
Given that I’ve got this extra time, I’m going to take you a little bit
deeper and show you the exact questions we use and give you an idea of how we
go about ascertaining whether a specific child has a medical home or not.
The National Survey of Children with Special Health Care Needs is a joint
effort between NCHS and the Maternal and Child Health Bureau at HRSA.
MCHB is dedicated to the goal of 100 percent of all children with special
healthcare needs having medical homes. It is one of their key performance
measures for their state programs. It is one of the Healthy People 2010
And in order to get at that and to have data for those objectives and
performance measures, MCHB established the National Survey of Children with
Special Health Care Needs. They provide the funding support. They provide the
direction for the survey. NCHS provides the expertise and how to get a survey
done and conducts the survey on their behalf.
The survey was first in the field in 2001. We repeated it in 2005-06, and
we’re scheduled again to be in the field in 2009-10, essentially being able to
get a benchmark for the beginning of the decade and ultimately look at how
things worked out roughly 10 years later.
The National Survey of Children with Special Health Care Needs is a
random-digit-dialed telephone survey. That means we randomly dial telephone
numbers in all 50 states, plus the District of Columbia, looking for households
So, first, we have to find a household, so, hopefully, somebody picks up
the phone, find out that it’s a household, ask them whether they’ve got any
children under 18.
If they do, we then screen all of the children in the household for special
Now, when I talk about special healthcare needs, I’m talking broadly the
definition as established by the Maternal and Child Health Bureau, which is
that children have a chronic condition and experience healthcare needs that are
above or beyond what children generally experience.
So the way we identify that is through the CSHCN screener. It’s five
questions, asks about specific healthcare consequences, need for prescription
medication, need or use of more medical care or other services than is usual
for most children, a limitation in activities or in their ability to do things
others can do, need for special therapy — such as physical therapy,
occupational therapy, speech therapy — and need for treatment or counseling
for an emotional, developmental or behavioral condition.
A yes answer to any of these five consequences triggers two follow-up
Those follow-up questions ask, first, “Is this due to a condition, as
opposed to, say, taking birth-control pills, which would be to prevent a
condition?” and, “Is this condition chronic? Is it something that has
lasted or is expected to last 12 months or longer?”
Provided we get a yes to a consequence and then yes to both of the
follow-ups, the child is considered to have special healthcare needs.
Now, we screen all of the children in the household for special healthcare
needs, and then if there are any children with special needs, we have a
detailed questionnaire about their health and their healthcare.
We select one child with a special need from each household. So if there’s
more than one, the random selection process to narrow the interview now down to
And the goal is to complete 750 detailed interviews for children with
special healthcare needs in each state. And we call and we screen households
until we meet that target in all states.
The respondent is the parent or guardian who’s knowledgeable about the
health of the child, that’s usually the mother.
It’s an interview that lasts roughly 28 minutes on the telephone, and we
conduct those interviews in English, Spanish and four Asian languages.
Just to give you an idea of what this means for sample size, we have to go
on and we have to screen a lot of households to find not only households with
children, but then households with children with special healthcare needs.
So in 2005-06, we screened over 364,000 children. That was out of about
200,000 households, and you can see that it varies by state.
We ultimately completed 40,840 interviews for CSHCN. We just missed our 750
target in Alaska. We ended up getting as many as 939 in California, and that
was — In an effort to keep our response rates high, provided that we’re still
in the field, we will still continue to try to go after individuals who we
still have not completed an interview with, and sometimes that gets us more
than our target.
Our response rate, overall, was 56 percent. That does take a hit because
there’s a lot of phone numbers that ring without an answer at all, and we have
to assume that some of those probably reach households with children and have
to take a hit to the response rate as a result.
The questionnaire itself, as I said, covers a lot of issues in health and
healthcare, but medical home is a substantial portion of this questionnaire.
And so now I want to just go through what questions we use to assess the
Starts with whether or not the child has a usual source for care, and
there’s a series of questions here starting with is there a place that the
child usually goes when he or she is sick or you need advice about his or her
health. Yes answers are followed with, “What kind of place is it?”
We then ask if there’s also a place that the child usually goes when he or
she needs routine preventive care, such as a well-child checkup, and, again,
what kind of place is it.
Provided that they have a place and that that place is not identified as
the emergency room, we consider that to be a usual place for care.
And you can see that 94 percent of CSHCN have a place for sick care and 97
percent have a usual place for preventive care. Then we ask about a personal
doctor or nurse. I know Dr. Bethell talked about this, to some extent,
The question, as we ask it, is whether or not the child — whether the
parent has one or more persons that they think of as the child’s personal
doctor or nurse, and that “or more” is important for this population.
It’s not focused specifically on a single primary-care provider, but rather
whether there’s at least one person, but there can be others who know the
child’s health history and know the child well.
Then we move to the referrals issue. Did the child need a referral to see
any doctors or receive any services in the past 12 months, and, if so, was
getting referrals a big problem, a small problem or not a problem.
And we find that 79 percent of those needed referrals reported no problem.
Now, we move into the care coordination and communication aspect of the
“Overall, are you very satisfied, somewhat satisfied, somewhat
dissatisfied or very dissatisfied with the communication among child’s doctors
and other healthcare providers?”
We had originally, when we first started fielding this survey, asked
parents whether their doctors communicated well.
We found that the parents really didn’t know how well the doctors
communicated, but they knew if they were happy with the outcomes, whether they
were satisfied with how well it was working.
This is certainly an issue that we have to deal with all the time with what
can parents report and what really don’t they know about.
So we look at communication between doctors, and then we ask whether the
doctors or other healthcare providers need to communicate with other
service-sector providers — such as schools, early-intervention programs, child
care, vocational education, rehabilitation — and, if so, then whether the
parent is satisfied with the communication between the healthcare providers and
those other service-sector providers.
And you can see here that, here, things generally start to fall off, only
about half of those needing the communication reported being very satisfied
with that communication.
And then we move on to what we tend to think of as care coordination, and
that is, “Does anyone help you to arrange or coordinate your child’s care
among the different doctors or services that he or she uses?”
We ask whether the parent felt that they could have used extra help
arranging or coordinating that care, and, if so, “How often did you get as
much help as you wanted with arranging or coordinating your child’s care?”
And we find that about two-thirds of parents or the parents of two-thirds
of CSHCN who needed help coordinating care reported usually or always getting
sufficient help with that coordination.
Now, recognize again this is not a question of who. We were not asking
whether it’s somebody in the doctor’s office or whether it’s somebody at the
healthcare plan who’s providing that coordination, just are they getting the
help that they need.
And then we look at family-centered care. We’ve got a series of six
questions here to get at whether that care recognizes the importance of the
parent in the child’s life and that the parent needs to be the primary source
of information about the child and at least a key person in making decisions
about the healthcare for the child.
So, “During the past 12 months, how often did your child’s doctors or
other healthcare providers spend enough time with him or her, listen carefully
to you, help you feel like a partner in his or her care?”
“When your child is seen by doctors or other healthcare providers, how
often are they sensitive to your family’s values and customs?”
And, “How often did you get the specific information you needed from
your child’s doctors and other healthcare providers?”
Then for children whose parents don’t speak English as their primary
language, we ask about interpreters, whether an interpreter is needed and,
“If an interpreter is needed how often were you able to get an interpreter
to assist you?”
So put all those together and the components of the medical home that we
address are: Usual source of care, personal doctor or nurse, no problems
obtaining referrals, whether a child receives effective care coordination and
whether the child receives family-centered care.
The measurement of medical home in this case — because we have to make a
determination of whether a child does or does not — a straight dichotomy —
does or does not have a medical home — because you ultimately need to come up
with a percentage for Healthy People 2010 objectives — is an all or nothing.
If you’ve got all of these things, then the child has a medical home. If
they’re lacking any one of those items that I showed you, then the child does
And you can see that 47 percent of CSHCN had a medical home in 2005-06 with
a minimum of 37 percent in D.C. If you don’t like D.C. being considered a
state, 39 percent in Alaska, and a max of 57 percent in Iowa.
Let me pause here for a moment and just talk about, probably reiterating
some of the things that Dr. Bethell talked about yesterday, in our assessment
of whether a child has a medical home, there are several components that are
We don’t ask about accessibility. We don’t ask about continuity of care. We
don’t ask about the comprehensiveness of the care that can be provided by a
primary-care provider or even the comprehensiveness that can be provided within
Part of that is due to the length of the survey. You know, as Dr. Lefkowitz
talked about, time is precious and it’s hard to add a whole lot into these
national surveys. We’re already talking on the phone to someone for an average
of 28 minutes. It’s hard to imagine them wanting to stick around for a whole
But we also have to only include questions that are amenable to parent
report. So asking about accessibility, for instance, a parent has never tried
to get ahold of the pediatrician in the middle of the night, they’re not going
to know whether or not they could do that, unless they’ve tried, for example.
But most importantly, I want you to recognize that our assessment of
medical home takes a systems approach. It is looking at the system of care,
making the assumption that a child receives care from a network of healthcare
providers and other settings where both child, parent, healthcare providers and
others all need to interact.
This is not an assessment of quality of primary care, as Dr. Starfield, I’m
sure, would tell you, if she was still here.
If we wanted to get at the quality of primary care, we’d essentially have
to go through a lot of these questions again, asking it specifically of the
primary-care provider; that is, you know, “Is your personal doctor or
nurse your primary-care provider?” “Do you have any difficulties
obtaining referrals from your primary-care provider?” “Does your
primary-care provider spend enough time with you, listen carefully to
you?” and so forth. And we simply don’t have the time in the survey to do
that. So we’ve taken that systems approach instead.
In terms of future plans, this battery of questions for the medical home is
also included in the 2007 National Survey of Children’s Health. This is also a
survey sponsored by the Maternal and Child Health Bureau. It includes data for
90,000 children regardless of whether they’ve got special needs. So it’s a
general-population children’s health study, using the same medical-home
questions. So we’ll be able to look at differences in medical home between
children with special needs and those without. Those data will be out early
And then, as I said, the National Survey of Children with Special Health
Care Needs is going to be repeated in 2009-10, and while we’ve got a technical
expert panel that has been formed and is advising the Maternal and Child Health
Bureau on the content of the survey, that group has met once and nobody had any
suggestions for changes to the medical-home section. So I’m not anticipating
that there will be changes in the coming years.
DR. STEINWACHS: Stephen, thank you very much.
Dr. Catharine Burt, please.
DR. BURT: Well, good afternoon, everyone.
I’m going to be talking primarily about the ambulatory-care component of
the National Healthcare Survey, which you may or may not be familiar with.
It’s a family of provider-based surveys that cover not only ambulatory
care, but also hospital and surgical care, inpatient care and long-term care,
such as nursing home survey, home and hospice care survey and a new survey,
residential care facilities, which is of assisted-living facilities.
So our approach to what is the medical home is almost the total opposite of
what Stephen has talked about, because we don’t talk to patients at all in any
way, shape or form.
So I’m going to be talking primarily about the National Ambulatory Medical
Care Survey, which is an encounter-based survey of office-based physicians, and
I’m going to tell you a little bit about the background of that, in case you’re
not familiar with it, and some of the data elements that we collect that you
may be interested in as it relates to medical home.
So the NAMCS has been conducted periodically since 1973.
How many of you are already familiar with the NAMCS?
So half the people. That’s not bad, I guess, being in the field since 1973.
We have a sample of typically about 3,000 physicians, but, lately, we’ve
increased it to about 3,600 physicians, and we end up with a sample of about
31,000 to 35,000 encounter records.
NAMCS is the national probability sample survey of office-based physicians.
It’s a complex sample design where we randomly select 112 different geographic
areas around the country, including the 50 states and the District of Columbia,
and within each of those areas, we stratify physicians from the AMA and the AOA
master files by their specialty, and we have 13 broad specialty categories and
then sort of a catchall.
So physicians are sampled by specialty, so that we are basically
over-sampling like dermatologists and neurologists and under-sampling internal
medicine and GFP.
Staring 2006, we also added 104 community health centers that are within
our primary sampling units, and within each community health center, we sample
three providers, not only the physicians who work there, but also nurse
practitioners and physician assistants.
The data are collected by the Census Bureau. They go to the — have a
face-to-face interview with physicians to induct them into the survey. They ask
them a bunch of questions about their practice, and then they show them how to
sample about 30 records from a randomly-assigned week during the year to give
us the data.
Now, the physicians must be primarily engaged in office-based patient care
and so designated by the AMA or the AOA.
We exclude federally-employed physicians. So we’re only getting at
non-federally employed physicians. We do not include the specialties of
anesthesiology, radiology or pathology.
And, further — Comments from the gallery down there?
DR. STEINWACHS: The gallery down here was noting that that’s where the
money is, and maybe because they don’t have to report, they make more money —
DR. BURT: Could be. We take a significant amount of their time.
But after we select the physicians — and we do it based on their
specialty, and we go to them and we find them and they are in practice — we
then find out what locations they serve, because some locations are out of
scope as well as physicians being out of scope.
But in scope are free-standing, private, solo or group practices, clinics
and urgicenters, neighborhood medical and mental-health centers,
privately-operated clinics, non-federal government clinics — such as a county
or a city clinic — health-maintenance organizations, community health centers,
But the vast majority of the physicians that we get are in private,
free-standing, solo and group practice. By far, those are the majority.
Now, the locations that are out of scope, if a doctor tells us that he
works primarily in a hospital emergency department or an outpatient department,
they are out of scope for this survey.
We have a sister survey called the National Hospital Ambulatory Medical
Care Survey that samples visits to emergency rooms and outpatient department
Also, ambulatory surgery centers are not included here because we include
them in another survey, the National Survey of Ambulatory Surgery.
But we also exclude institutional settings, such as schools or prisons,
industrial outpatient facilities or occupational facilities — like if where
you work has a health clinic for the employees there, that would be out of
scope — any federally-operated clinics — such as VA or military —
laser-vision surgery, et cetera.
One other point I want to mention that is out of scope are university
health clinics, places where only the students can go, but the general —
Basically, if the general public cannot get in there, it’s out of scope.
In the interview data, we ask the — We know the physician’s specialty when
we sample them. We verify that. We ask them questions about their electronic
medical record usage, parameters about the practice, like how many physicians
are in it, who owns it, sources of revenue in terms of percentage of
patient-care revenue by Medicare, Medicaid, self-pay, private insurance.
We ask a battery of on-sight diagnostic services that they might have
there, like X-ray machines or MRIs, the use of — how many midlevel providers
they have in the practice and their willingness to accept new patients by payer
type, the source of payment.
And I left for you out on the table here, this is our latest report from
the Physician Induction Data. It combines 2005 and 2006, and it has many of
these statistics in it.
So in the encounter data, where we go in and ask them to sample
approximately 30 records during a one-week reporting period and abstract
information from the medical record for that visit onto a one-page form that
asks about the patient’s age, sex, race, ethnicity, expected source of payment,
the number of visits made to this provider within the last 12 months, whether
or not this physician is the patient’s primary-care provider, which we have
defined as the provider who coordinates most of their care.
So we didn’t know about medical home back whenever we added this item —
1997 — to the form, but it’s really meant to get at that notion.
So it’s not to be confused with the specialty of the provider, which may be
a primary-care-provider specialty. This is really asking, “Are you the
patient’s primary provider for care?”
In addition to that, we collect up to three reasons for visit and
complaints, up to three medical diagnoses.
We have a chronic-disease check list for about 12 chronic diseases.
“In addition to the diagnoses, does the patient also have any of these
We ask about disease-management programs that the patient may be enrolled
in, screening and diagnostic services that are ordered or provided at that
visit, treatments provided, drugs that are prescribed, including
over-the-counter, and providers seen at this visit and the duration.
And by “providers,” it’s the type of provider. Was it a nurse, a
doctor, a nurse practitioner, physician assistant, et cetera.
So here are some statistics from our data. This is the — even though we
sample physicians, we are able to convert the physician-level data into
practice-level data, because we ask about, “How many physicians are in the
practice with you?” and we can reweight the data to get at practice-level
So this particular slide has to do with the number of medical practices
that have these things on site ready and available for patients.
Obviously, EKGs are at the top, followed by lab testing, but X-ray
equipment is available for 16 percent of practices and MRIs and CT scans are
sort of down at the low end.
This slide has to do with the percentage of office-based medical practices
that have midlevel providers in the practice, and, as you can see,
multi-specialty groups are more likely to have a midlevel provider involved
than a single specialty either group or solo practice.
We asked some pay-for-performance questions for the first time in 2006.
Kind of disappointed with the response. Information was missing about 20
percent of the time, but they indicated that quality-of-care measures and
patient satisfaction measures were involved with their pay for about 22 to 20
percent of the physicians.
Percent of primary-care providers using electronic medical records by
setting type. And here you notice that what I said was that we had the most of
happened to have the least percentage that are using electronic medical
records, which is like 5.4 percent of physicians in solo or partner practice.
It goes up to 35 percent for other office settings, and the fine print on
this — Do you have copies of this?
DR. BURT: Okay – is that it includes HMOs, faculty-practice plans and
urgent-care centers are included in that other group.
And this is the distribution of patients by those kinds of offices. As I
said, most of the patients are seeing private or solo practitioners.
These are in millions of patients. Only 2.7 million patients go to a
community health center. Only 11.7 million patients go to office visits.
Now, those of you who are familiar with many of our reports and
presentations understand that this is encounter-level data, and, normally, we’d
speak of visits, but this is, in fact, patients, because we use that item
about, “How many times have you been to this physician in the last 12
months?” to reweight the data to get at a patient level.
And a patient is defined as a one-to-one relationship between a particular
person and their doctor. So if you have two doctors, you are two patients in
this system. So that’s the way the patients distribute themselves.
And if you talk about the patients who see a doctor who uses an
electronic-medical record, then you see that these millions of patients, which
were up around 67 million in some of these groups, comes down to about 4-1/2
million in private and solo practice, nine million in group practices, less
than a half a million in community health centers and about 3.4 million in
So if you wanted to get at some measure of how many people have a medical
home that has electronic medical records, these are patients who went to their
primary-care provider during the year.
So, as Doris mentioned, 20 percent don’t go to any doctor in a year, and so
they’re not included in these things. In our statistics, you’ve got to come to
So that represents about 13 percent of all patients who are seen in a given
year by their primary-care provider.
We also can look at quality of data because we have all these diagnostic
and screening services, ordered or provided. People often use our data to sort
of — for various reasons, for medications or screening devices or whatever,
screening tests, to see what percent of the primary-care provider’s visits had
this particular service.
And blood-pressure readings, taken among adults, PCP visits, as you see,
has gone up from about 75 percent to almost 90 percent during the first half of
Also, you may be of interest (sic), the patient complaints are the leading
reasons for visits. These are the top reasons for visits that patients provided
in their own words for going to see their primary-care provider.
And the general medical exam, progress visit, well-baby exams, routine
prenatal exams take up the majority of these on this list. This list accounts
for about a third of all the reasons that patients give for going to the
Now, if someone wanted to modify our surveys to do something, as Doris
indicated, it takes a while, has to go through OMB clearance and the forms have
to be printed, training has to be created, et cetera, but some of the things
that could be done is that you could ask in the induction interview, “Does
the provider bill for medical-home services?” assuming that a doctor would
recognize and know what that means.
On the patient-record form, you could ask, “Is this the patient’s
medical home?” I doubt seriously that’s in the medical record.
I’m not sure what, in the medical record, will tell you that this is the
patient’s medical home.
The other thing that can happen is the NAMCS can be changed from a sample
frame of physicians to also include a separate, independent sample frame of
nurse practitioners and physician assistants to gain at the places where —
Most of the care that’s provided in that practice is from a midlevel
provider, rather than a physician, and this goes back to that slide I had very
early on about our in-scope locations, and I said that, yes, we do have these
other locations, but we don’t have a lot of visits there. And one of the
reasons we do is that the ratio of doctors to midlevel providers is much lower
in those kinds of practices, and we’re, in general, only getting the physicians
And to the extent that there are places like Wal-Mart, these retail health
places where anybody can go and see, usually, a midlevel provider and they can
get — I don’t know that that’s their medical home, but it might be, but we’re
not getting any of that.
So modifications to the survey can be made at all levels — at the frame
level, the scope level, the induction interview and at the patient record forum
level, with the only caveat that the stuff has to be in the medical record,
because we don’t ask the patients anything directly.
So this is my contact information, and I’d be happy to answer any questions
you might have individually or globally.
DR. STEINWACHS: Catharine, thank you very much.
Let’s open it up for questions and comments to all three presenters, a rich
discussion of our data sources.
Let me ask one question. I’ll just start it off.
You talk about the time frame, but I don’t remember whether either one of
you, talking about time frames, gave a year estimate. Is it about a three- to
four-year lead time?
DR. BURT: Well, how long does it take to grow a small beard?
DR. STEINWACHS: How long does it — I don’t know. I think overnight —
doesn’t it? — if it’s small.
DR. BURT: Well, for example, we’re making some changes to the 2009 survey
right now. We are adding ambulatory surgery centers to the hospital NAMCS, as
we speak, and that goes into the field in January.
DR. STEINWACHS: So if you change the scope, are you telling me that —
DR. BURT: That takes longer.
DR. STEINWACHS: Scope takes longer, but content of the questionnaire is
shorter or —
DR. BURT: Yes.
DR. STEINWACHS: I see.
DR. BURT: Right. And we routinely sort of add items and take items off
every two years.
But in 2011, we are doing a more drastic change to the survey. We’re
finally getting a new sample of primary sampling units, because our current
ones, now, were from the 1985 health-interview survey, which was based off of
the 1980 census. So —
DR. STEINWACHS: Which was the last good census, right?
DR. BURT: Well, you know, ’90 was pretty good.
So then it does take a while, but there we will be investigating other sort
of scope issues, and our plan is to pull together a technical-expert panel to
meet some time this winter to sort of feed into should we — you know, how
drastic do we really need to modify this survey. Is it just a question of
tweaking some of the content or is it really a question of changing the scope
like to include university health centers, so we have college students included
in this, because our estimates of STDs may be a lot lower than one might
imagine or whatever.
DR. STEINWACHS: Doris, just a question on MEPS. I assume the timeframes are
about the same for MEPS or —
DR. LEFKOWITZ: I mean, a simple substitution of a question or adding a
simple question here and there is a couple of months before the administration.
Something that was more substantial, I think, would be probably in the
So, you know, I would say six months to two years, depending on what it is.
DR. STEINWACHS: OK. Thank you. Larry, please.
DR. GREEN: Two questions, one for all three of you and one for you,
What do these three surveys cost currently? What does MEPS cost —
DR. LEFKOWITZ: In what kind of metric? Per case? Per year? For what
DR. GREEN: What’s the budget for operating MEPS for a year?
DR. LEFKOWITZ: Fifty-two million.
DR. GREEN: And for the child survey?
DR. BLUMBERG: I can’t give it to you annually. For the entire survey, $10
million to $12 million.
DR. BURT: I’m your biggest bargain here. (Laughter). The NAMCS pulls in at
about $3 million.
DR. GREEN: Catharine, my question for you — this is an opinion question —
if I tracked that correctly, the induction survey is really the way in which
you get the information about the constructs, the services, the structure of
the practice, who works there, how many people, that sort of stuff.
In your opinion, is that a — let me choose my words carefully — is it a
prudent potential target for developing measures of the medical home to be
DR. BURT: I think it’s possible that it could be used in that way to the
extent that the questions can be asked in a way that every physician — or, in
some cases, the physician doesn’t fill it out. Someone in the office takes the
interview, but they have to know the concepts that are being asked about.
Like, for instance, when we were asking about, “Is productivity
involved in your pay?” 30 percent of the doctors said no, but that doesn’t
make sense — you know? — because some — yes, some are under salary, but
that’s a very small proportion.
So either they didn’t understand this concept — that the more you see the
more you get paid or — (laughter).
So you understand the sort of dilemma on that. They have to be able to
understand this concept.
And, you know, when we used to ask about capitation for payment at the
visit level, the people in the office couldn’t answer that question.
DR. GREEN: If I could react to that, this harkens back to the mid-‘90s
when the Institute of Medicine decided, it’s 20 years later, and they should
study primary care again, and you’ll recall — you may not recall — but that
study was suspended while the work turned to writing a separate report that
defined primary care.
And the reason that happened is that normal people in the country had such
a poor concept of primary care and what it meant to have a personal physician
or how you get your care that they couldn’t talk about it. They couldn’t
complete a question. They couldn’t answer the questions, because they didn’t
know the concept. They hadn’t experienced the concept. They hadn’t seen it and
they didn’t know what it was.
That led to a little blue book that defined it, and then they proceeded to
use that definition to do it.
It seems to me we’re right back there again. We have such a poor concept of
integrated care, these basic attributes to the medical home, that when we get
together, even a group like this, we have a hard time talking to each other.
And we’ve now only heard, in the last day-and-a-half, at least a dozen times,
people say, “What the hell are you talking about? Are we talking about the
DR. MC GEENEY: Thanks, Larry. I want to respond to that, too.
The patient-centered primary care is really acutely aware of that. They
hired a consultant to just test the consumer recognition for the phrase
“medical home,” and there was very, very poor acceptance or
understanding of it. A lot of people actually interpret it as a nursing home or
someplace to go to at end of life.
So we’ve got a major selling job ahead of us, and I think one of the
charters of the PCPCC is to do some pilot studies and actual focus groups and
try to come up with a more salable and sellable name for the consumers.
MR. NOHRDEN: (Off mike) — a member of that group?
DR. MC GEENEY: I don’t know. Good question.
DR. KLINKMAN: This gets back a little to what Larry just said, but this is
for Catharine as well.
I think, when I look at the information coming out on your slide about the
types of reasons for visit and the frequencies, it really is quite different
from those we’ve gotten at my site using a different construct for reason for
And I think, again, like Larry was saying about the sort of medical-home
questions or the other questions you’re going to answer, this is the
physician’s own sort of distilled interpretation of why somebody showed up —
DR. BURT: No.
DR. KLINKMAN: — and a general follow-up —
No? The patient writes this in? It’s reconstructed from the record, right?
DR. BURT: It’s supposed to be reconstructed from the record as what the
patient said was the reason —
DR. KLINKMAN: Yes. Yes, but in actual practice what happens there is that
probably 99.8 times out of 100, it’s called the “chief complaint,”
and it’s a highly distilled version of what the patient originally presented.
Because when I go into my rooms now, when my medical assistant will put in
the reason why it’s there, it’s, “Follow-up,” “Checkup,”
“General health exam,” when the patient and I both know that they’re
there for follow-up of this problem, this problem and this problem that are
So there’s sort of a data-validation issue there that it will be good to
try to disentangle.
DR. TANG: I was impressed by the children with special needs survey. It
seemed like, even though you didn’t have the concept of medical home, those
questions were easy to understand, presumably easy to answer and really spot
on, from what I could tell.
So I — one, I thought that was — rather than 220 questions, I thought it
was a pretty good way of figuring out whether this concept existed.
The other thing is I’m not so sure I would interpret the 50-percent bundled
composite score to be that bad.
If we look at an SMA-18, I mean, you have less than a 50-percent chance of
being — quote — within normal limits on that panel. So when you combine it
all and you only have one or two questions that had sort of close to 50, which
brought the overall composite down, but it —
So it seems like for pediatrics, and particularly for this population, they
seem to have such a thing, and I don’t think adults would — certainly, the
middle group of adults would — I’m still sort of awed by calling 400,000
people randomly — families, but —
MR. LAND: Also, on the special healthcare needs survey, have you been able
to determine what bias is created by not getting into the cell-phone homes?
DR. BLUMBERG: Well, you’re asking the right person. The other hat that I
wear happens to be the person who tracks the incidents of cell-phone-only
households in the United States, and we get that from the National Health
The advantage of getting it from the National Health Interview Survey is
that we are able to look at differences in health measures between land-line
telephones or people who have land-line telephones and those who do not.
PARTICIPANT: Because it’s in person.
DR. BLUMBERG: Because it’s in person, correct.
So far, we have not seen dramatic differences between those with and
without land-lines when it comes to children’s health measures. That’s not to
say that we’re not going to.
We know that there are some differences in health insurance, but, so far,
we’ve been able to adjust those out by controlling for issues such as poverty
and education status and so forth.
So, right now, statistically, we can accommodate it. That’s not going to be
true in the future, and the 2009-10 National Survey of Children with Special
Health Care needs will include people who are cell-phone only as part of the
DR. STEINWACHS: I want to thank the three presenters. This was really very
useful in giving us an understanding of our current capacity and raise those
opportunities for us to think about what the future might bring, but all the
cautions that you gave us about that.
Thank you very, very much.
DR. STEINWACH: We are now going to turn to health information technology,
and the primary-care, medical-home measures, data and standards.
And we’re fortunate enough to have Mr. Chris Nohrden again helping us on
this, and Dr. David Hunt and Dr. Michael Klinkman.
So who’s going to — Chris, are you leading off or —
MR. NOHRDEN: Be happy to. Sure. Yes.
DR. STEINWACHS: OK. That’d be great.
PARTICIPANT: Do we have slides?
MR. NOHRDEN: No, I apologize in advance. I was a little bit late getting
the slides together, and I think I have two that I can show later. They really
will be illustrative, but I think I’ll just hold on them for now.
You’ve probably seen IBM slides before. They’re chock full of colors and
chock full of words, and sometimes they hit the message spot on, and I’d be
happy to send a collection of them on later to the organizers, if it would be
DR. STEINWACHS: That would be great.
MR. NOHRDEN: I’m going to have a little bit of a difficult balancing act
again today as far as the hats I have to wear.
As I mentioned yesterday, I’m the project manager for IBM’s
patient-centered primary care initiative.
I’m coming from an HR background for about the last 25 years, where I’ve
been working in occupational health and health benefits, and I’m now segueing
into the business aspects of IBM.
We’re actually exploring the landscape of the patient-centered medical home
and trying to understand how we can best support it from an
information-technology and solutions standpoint.
So what I’d like to talk to you about today are a particular project that
we are involved in in Denmark that I think a lot of you have heard of that’s
been — might even have been referenced by Dr. Starfield this morning.
And I’d also like to bring you some more messaging about the
patient-centered primary-care collaborative and a particular center that is
focusing on the impediments to e-health adoption in the patient-centered
medical home, which I think will probably be right on target for your sorts of
I think, as you’ve heard from a number of the speakers, both yesterday and
today, that there have been studies from around the world that really validate
the value of patient-centered primary care, but that is when it is combined
with advanced e-tools, and those e-tools being elements such as email
consultations, electronic health records, clinical-decision-support tools, and
particularly those tools that are linked with evidence-based-medicines
guidelines for care.
And when patients receive this sort of care in those sorts of
patient-centered medical homes, real true value is added to the healthcare that
And as I think I made the point loud and clearly yesterday, and which I’ll
hearken back to again today, this is the model of care that IBM, as a large
employer, wants to buy for our employees. And we’re not alone in this charge.
We really recognize it. It’s not only going to solve a lot of structural and
systemic problems with healthcare in the United States, but, in the end, our
employees are going to get much better care as a result.
And the global example that I wanted to talk to you about today is that of
Denmark, where the company called Akire(ph), which is an IBM subsidiary, helped
to create a patient-centered medical infrastructure that is actually the Danish
national e-health internet portal. It’s known as Sundhed. That’s
S-U-N-D-H-E-D.dk, if you wanted to go out and take a look at some of the glitzy
interfaces, and it utilizes quite a number of IBM technologies and solution as
part of its infrastructure.
The coolest part about it is that any IBM Danish citizen has access to it,
as well as any IBM Denmark healthcare provider.
It’s a highly-secure website. They have been able to resolve the issues
about privacy and security that we had a little bit of discussion about
Patients can schedule their doctors’ appointments. They can go in and see
the free times and schedule same-day appointments. They can receive appointment
reminders. They can receive medication-refill reminders. They can actually
check on waiting times before their appointment comes up. And doctors can
actually admit and discharge their patients remotely over an internal portal
using this technology.
Each hospital actually makes its electronic health records available
throughout the system, so, with the right level of security and access control,
any physician can actually see the history of treatment of a particular patient
that they may be rendering care for.
There’s a consumer layer to this as well, where patients have their own
personal health web page, where they can monitor their health.
They can also determine who’s accessed the records, back to the point about
And reliable medical information is there, such as we can access from
producers such as WebMD and other similar products, where you can do more self
service, self information, self-guided-type learning about your health
And you can also get competitive costs, comparative costs for different
procedures that you may be contemplating, which is another standalone-type of
application that we have here in the United States from a number of different
The patients in Denmark and the physicians work hand in hand to really
maximize their healthcare experience using this sort of solution.
Each physician has a panel of 1,500 patients, and they receive fees in
accordance with the types of additional services that they render, which would
be considered to be the add-ons that we’re looking for as the basis of the
patient-centered medical home.
E-prescribing is an automatic part of the whole system. So prescriptions
are filled electronically — prescribed and filled electronically.
And during emergencies, the doctors can actually see the patient in person
or prescribe prescriptions remotely through e-consultation.
So it’s an all-encompassing sort of platform that really addresses these
needs that we see for the patient-centered medical home.
In July of 2006, the New England Journal of the American — the New England
Medical Journal Association — the Journal of the New England Medical
Association — I’ll get it correctly — was quoted as ascribing the medical
error rate in Denmark to a staggeringly low 0.4 percent. It’s probably the
lowest in the world, bar none.
The Ministry of Health in Denmark has indicted that this has been reduced
even further, and they really attributed their ability to maintain this amazing
focus on medical error rate reduction because of their focus on
patient-centered medical care.
So before I try to sell this as the best thing since sliced bread for what
we’re talking about here in the United States, understand that this is very
unique to Denmark.
There are some uniqueness about the Denmark medical market, their medical
environment that are going to make it difficult to just pull that over here and
use it as is in the United States, and that’s something that we’re currently
exploring and sizing in terms of the further investment that would be needed to
tailor it for a U.S. market.
But what really are some of the primary issues that are effecting this in
the U.S., as far as the data integration like we’re able to see there in
Denmark, most of the electronic health record tools that are used in small
practices, where a large percentage of healthcare is received in the U.S., do
not really integrate well with disease registries, and Terry McGeeney made this
point yesterday. I think Allen Dobson also reiterated it as well.
There’s a separate data-entry factor that’s needed when you’re working with
electronic health records versus disease registries, and anytime you have
separate entries of data, you’re entering errors, you’re — either commission
or omission — and I think this is really one of the greatest shortcomings that
we have with our current generation of electronic health records.
And I’m happy to hear From Terry that there are actually some vendors that
are stepping up to that and addressing that, but I think we have a long runway
ahead of us before we really resolve that problem.
Another deficiency that we’re seeing is that the clinical-decision support
tools that the providers need are really not well integrated within the
electronic health reCords as well.
If you want to understand what’s the best — actually have some guided
influence on how your decision-making process is working, what are your best
treatment options, you’ve got to go to a separate place in order to get that
information and then come back into your electronic health record, and that is
another interruption in the patient-physician interaction, and that’s really an
impediment, I think, to good medical decisions and also perhaps — disease
management and medication management as well.
This is another item that came up in one of our recent summits at the
patient-centered primary-care collaborative, but there’s a heroic amount of
effort that’s needed to generate reports on metrics and outcomes.
Oftentimes, there are chart pulls needed. There’s a coalition of data from
a number of different sources, and, ultimately, it needs to be as simple as
just hitting a function key on a keyboard in order to generate whatever type of
metrics are needed on the practice level, either outcome metrics or
quality-of-care. And I think this is a long, long way to go before that becomes
reality, and be happy to hear from anyone in the audience if you are aware of
people who are actually stepping up to this particular point and addressing it.
And last, but not least — and I’m sure when you hear from David Kibbe,
who’s, I think, slated to speak today — there is really a great degree of need
for more openness in the standards for the actual exchange of data. There’s an
awful lot of proprietariness at this point amongst the different vendors, very
much closed systems that are not easily plugged and played into other systems,
and I think probably — I know you folks are involved in this through the CCHIT
process. I think CCHIT alone is probably not going to be enough to address
this, and there is going to be — need to be other national influence and
national efforts, I think, that are focusing on this whole aspect of
As I mentioned yesterday, IBM was instrumental in leading to the
establishment of the patient-centered primary-care collaborative back in 2007,
and we currently have four groups that are focusing on a number of different
aspects of patient-centered medical-home implementation and also the
The particular center that I’m supporting is devoted to e-health
information, adoption and exchange, and we’re focusing on what’s really the
basic technology infrastructure that will be sufficient to support the
patient-centered medical home.
You may have seen an announcement in either the Wall Street Journal or the
New York Times, I think within the last week or two. This is going to be led by
Dr. John Agwinobe(ph) who was the CMO of Wal-Mart, and he’s also the former
Assistant Secretary of Health, and Dr. David Mase(ph), who is the CMO of
McKesson(ph) Health Solutions. And we have an overarching charter.
I guess I don’t need to bring up the slide. I’ll just read from that.
“We want to assure that a person’s relevant health data can be made
available when needed at the primary-care level from various sources, including
pharmacies, PBMs, clinical labs, nurse practitioners in retail clinics,
hospitals and other medical practices.”
So it’s really looking at anything that may impede that flow of information
to the point of care when it’s needed to inform clinical decision making.
We’re now at the point of actually forming three different working
subgroups, and I thought this may be of special interest to you, because this
really touches on a lot of the technology discussions that you’re having today,
and I think there’s great need for us to collaborate even further on it as we
We have a first subgroup that’s going to try to collaboratively influence
the PHR and EHR vendors in order to move decision-support tools, and also
reporting tools, closer to the point of care.
And one of the ideas that we have is to actually work with the trade
associations, the EHR VA, I believe it’s called and IHE or IHIE. Unfortunately,
I don’t recall the full acronyms, but I can actually flush that out and get
that back to you.
We’re pleased that Dr. Tom Coon) from ACP has agreed to lead this
particular workgroup, and we expect to hear a lot more from them in the future.
Probably before the end of the year, we should see some work products from that
workgroup as far as their initiating discussions with the vendor association
The second group that we’re forming is going to be about sharing best
practices for medical-home transformation or best practices for transformation
of practices to medical homes.
And we’re currently in discussions with Dr. Ted Iton(ph) from Group Health
in Seattle, and also Dr. Terry McGeeney, about leading this particular
And we have yet to actually lay out the path and the deliverables for that
particular workgroup, but we should have more to tell to you at an upcoming
meeting on how we advance on that front.
And the third and final subgroup is how can we really influence the free
flow of information to the practices or actually influence legislation that may
actually impede the free flow of information, and very pleased to announce that
Dr. David Kibbe has agreed to help us with that work effort, and I think we
have an exciting layout and an exciting charter and an agenda and looking
forward to coming back again and talking about some actual accomplishments of
the health center.
And, finally, in a similar vein, I wanted to mention that IBM has recently
published a white paper on data standards for PHR implementation, and since
there are a lot of interplays, interchanges between PHRs and EHRs, this kind of
helps, I think, better understand the landscape of what we may be up against as
far as EHR implementation, particularly as it effects the small practices that
are really cash constrained, I think, for investing in this sort of technology.
And this is available as a soft-copy PDF. I don’t know what would be the
best way to get that to you, whether — if you want to leave cards, if I can
maybe give it to Cynthia and have her distribute it secondarily to everybody.
DR. STEINWACHS: Yes, and also we could post the link onto the website.
MR. NOHRDEN: Perfect. Yes, I’d be happy to do that.
So, in closing — we’re studying some ways that we can make it maybe even
work here in the United States.
There are a lot of opportunities to improve data flows and particularly as
they relate to the data integration at the practice level, and I think that’s a
challenge for you. It’s a challenge for us in our patient-centered primary-care
We’d love to have a greater collaboration with you folks in order to take
that agenda forward.
DR. STEINWACHS: Chris, thank you very, very much.
I’d like to welcome Dr. David Hunt, who is the chief medical officer for
the Office of the National Coordinator for Health Information Technology, and
thank you for coming and joining us, Dr. Hunt.
DR. HUNT: Thank you.
When we get to the point where we can have a short acronym, you know, or a
short title, then our work is really done.
DR. STEINWACHS: Well, at least you have a performance metric here that we
can all understand.
DR. HUNT: I first have to bring greetings from the National Coordinator,
Dr. Koladner(ph), Dr. Robert Koladner. He’s going to be speaking tomorrow to
the NCVHS, and he sends his best wishes.
And, today, I’m really here to highlight two areas relative to the work —
to the patient-centered medical home and our work at ONC.
First is how the decisions regarding the national technical infrastructure
are prioritized and, second, what those priorities have produced that will be
useful in our discussion of the medical home.
First, though, I’d always like to start with an admonition, namely that we
refrain from inextricably linking health IT as the singularly-necessary and
sufficient component for the concept of coordinated care through a primary-care
When we link those two, we start to take on the role of Vladimir in Waiting
for Godot, just waiting for that one necessary component.
I’ve heard those talk about health IT as the panacea, and that’s convenient
because then we can just sort of sit back and wait for the folks who gave us
Killer Rap to ride into the rescue, and this type of expectation really
provides no realistic acknowledgement of the realities of our current
circumstance. It seems to make the case that if we just wait for the guys who
make Google or eBay to come out, everything will work and be just fine.
Early on in my medical-informatics training, I learned a cardinal rule,
namely that IT has never been the sole solution to any problem of substance.
While we do have a lot of technical challenges around bits and bytes, our
real greatest issues are actually cultural — and I think we’ve heard those
today and yesterday — such as how do we structure payment policy, the growing
consumer empowerment movement and a clinical establishment that is
schizophrenically loyal to anecdotal practice phenomenon and randomized
clinical controlled trials at the same time.
So the open question really is can we use technology as a vehicle — health
IT technology as a vehicle to change our culture, and, in turn, our methods, in
21st Century healthcare?
And I phrase that question very specifically because one curious
manifestation of our unqualified affection for the computer is an unfailing
belief, again, that on the morning of that great gettin’-up day, when there’s a
computer next to every stethoscope, that all our problems will vanish.
So with that as the context — I hope I haven’t been a total killjoy — I
hope to provide a case that we do have some essential gaps that can be filled
in providing coordinated care using electronic health records, personal health
records and the public health information system as key assets all adhering to
common standards operating over a secure network.
And that, in a nutshell, is the reason for the Office of the National
Shortly after our office was formed — and this is just an example. Please
forgive the small type. Shortly after our office was formed, the Secretary
created the American Health Information Community or AHIC, which most of you
are probably familiar with, as a committee to advise regarding relative
For the purposes of this discussion, I can highlight the committee advised
that ONC work to recognize standards for the following priorities.
First of all, consumer empowerment, which included basic registration and
The electronic health record, which included laboratory results reporting.
Consumer access to clinical information. Medication management. Remote
monitoring of clinical devices.
Critically important for this discussion also was use case for
consultations and transfers, as well as patient-provider secure messaging.
Now, the process of transforming this list of priorities into a set of
standards that IT professionals can create products for involves the
intermediary step of creating use cases for each priority.
“Use case,” many of you know, is a term of art in IT. It’s very,
very old. It was first formally described way back in 1987.
So, put briefly, use cases tell the story of what you want the software to
do at a very high level.
I’m sure you know this, but to recap, use-case documents, basically are
cave drawings. They’re made from those people who need to get something done to
those who know how to make computers to do — how to make computers do
They are in the form of descriptive scenarios that outline the actions of
users and the computer system to achieve the desired result.
So these documents, these use-case documents that we’ve been producing at
ONC are really the first step to what we will call “functional
For our purposes, after public feedback, this narrative of events is then
sent to the Health Information Standards Panel, also known as HITSP, and
they’re translated into specific standards all products can then be held
The entire cyclical process moves from the statement of priorities to the
description of scenarios to the identification of standards, which are then
tested, and, if successful, they’re recognized by the Secretary and used in
certified health IT products.
This clearly breezes over a lot of details, but the final result is that we
hopefully will have certified products that can then share information for the
coordination of care across the street or across the country over a secure
Now, these details actually make a tacit assumption that we should actually
make explicit for this entire process, namely, that we — and in this case,
this is the royal federal we — have to be able to make a strong statement
regarding the maintenance of security, which is a state of being, to help
patient privacy — protect patient privacy, which is their right, and honor
that sacred trust that — for those who care for them.
So we sometimes use these words interchangeably, but it’s important to
understand the distinctions in moving forward.
Now, assuming that these three — patient privacy, confidentiality and
security — can be achieved and maintained, we have a wonderful foundation for
And, to date, this process has been pretty successful, creating standards
that can be used to certify HIT products, and, in many respects, we’ve seen
more success in the last three years than we had in the previous 20.
With that, I’ll just sort of stop and recap, because I think the next
session I’m going to talk a little bit more about the actual implementation of
some of these standards, but I always like to emphasize that privacy and
security, they really are the soil.
Standards and a network backbone, the certification enabling processes from
the federal government, they really are the roots for this whole process.
And sprouting from all of this is a governance structure which is AHIC,
and, hopefully — well, not hopefully — we are in the process of transitioning
over from our current federal advisory committee AHIC to a public-private
entity, AHIC 2.0, also known as AHIC’s successor, available at
AHICsuccessor.org, that’s currently being stood up to actually continue with
this governance question and provide some form of reliable feedback in terms of
what are the priorities that we need to have.
Finally, if we’re able to achieve this, if we’re able to get all of this in
place, we really will have the fruit, the tools of which we should be able to
piece together to make a coordinated medical home.
And I’ll be able to talk about that in a little bit after the break, I
DR. STEINWACHS: David, thank you very much.
Our next speaker is Dr. Michael Klinkman. Mike is an Associate Professor at
the University of Michigan and will be talking about — when he brings up his
title, then I’ll know, I’ll be able to say what it is.
DR. KLINKMAN: Yes, I’m here to solve this panacea issue, I guess.
DR. STEINWACHS: Oh, wonderful. Is that a treatable condition?
PARTICIPANT: You should have gone first.
DR. KLINKMAN: This has been a long day, and my head, from taking all of my
day-job hats that I wear from helping to build disease-management programs that
are one offs — I’ve been up and down this scale so many times that I just
think we all need to take a deep breath before we get started in talking a
little bit about the same issues that Barbara Starfield raised this morning.
So with that being said, the piece, I think, as I’ve listened to all of the
speakers and all of the different, incredibly well-done, well-planned and
well-carried-out specific projects, starting yesterday at North Carolina
through Geisinger today, Barbara had a lot of no’s on the table that we still,
I don’t think, have really come to grips with.
So here’s her list from this morning:
We have no idea about how to handle the recognition of problems feature of
We have no draft instruments that give you criteria that measure
comprehensiveness of care.
We have no assessment of person-focused measures, because of comorbidity.
We have disease-specific measures, but not person-specific measures about
We have no evidence, at this point, that NEHR(ph) contributes to the
performance of primary care.
We have no agreement on what patient-centered primary care really means.
We have no evidence that the chronic-care model works as a patient-centered
We have 230-some items in the PPC PCMH, but missing pieces for all of these
We don’t have a use case for primary care in AHIC.
So we’ve got lots of no’s here. What’s missing, it still seems very clear.
We talk a lot about patient-centeredness and about the patient and we talk
about how the primary-care medical home is supposed to meet the needs of
patients as one of its primary aims, but we have no method in place to assess,
record or even elicit patient goals or preferences, no structure for that.
We don’t have a system that records, on a routine basis, why people come in
to see us. So we have no way of knowing where we start our care processes on a
routine basis. So there are still some really big holes here.
We’ve done a really nice job working at the margins and at the ends and
trying to use health IT to support that.
So, with that being said, here’s the big picture we want to take us through
over the next little bit of time: How the PCMH works, from my perspective.
OK. I will wear my hat as a practicing primary-care physician who sees
patients three or four half-days a week, who has a very large patient panel who
have lots of chronic health problems.
The gap between what we have now on the ground in everyday care and what I
think we need and why a better EHR isn’t the answer.
The importance of the right data model. You know, we’ve heard that a couple
of times today, and what it is at the core that we really need to do right in
order to understand and to be able to measure primary care. And, finally, what
building blocks might be useful and why.
And then I’ll finally make a plea for the fact that no matter what we do,
having local — meaning practice-based — control of that information, so that
the practice can use it to improve as a unit, or so that the doctor’s office
can use it, has got to be critical here.
We can’t farm this out to an EHR vendor who will give us back our results
in a month or two or will tell us how maybe we should do this if we just pay
them to write new software for data mining.
So here is the primary-care information problem. This is my life, Okay?
It’s bad. It’s getting worse.
We talked about activated patients. So you’ve got, over on the left side, a
patient who has been out on the web pulling in information, talking to their
friends, talking to their grandmother, and they’re activated. “There’s
something wrong here. I gotta do something about this.”
But the problem is that information acquisition is incomplete. It’s
potentially inaccurate, and it’s expanding rapidly.
One of my patients came in the other day and said, “I spent the last
four days on the web trying to find out what was going on to bring in to you
today.” How do you respond?
Well, but the patient, then, has to self-filter that information, don’t
they? They’ve got to try to figure out what’s relevant to me in the few minutes
they can spend with me. They’ve got to figure out where to go with it.
They can go to this plethora of people off on the right. They can go to me.
They can go to one of my partners. They can go to one of my competitors. They
can go to any of several specialty providers.
But they have to self-filter that data. So some of it is lost. Some of the
important flows, the big, dark, black arrows get lost.
And then when I get it, I gotta somehow do something with it, you know.
It’s selectively presented to me. So I need to elicit maybe something else that
was out there that they didn’t think to bring in.
When they go to a specialty provider, they have directly to present
self-filter data. So they tell the cardiologist what they think the
cardiologist wants to know, but they don’t have any idea about what the
cardiologist really needs to know.
And, finally, when they do see the specialist and they come back to see me,
we have no way of moving that information routinely back and forth. So I will
get a report through the patient of what the doctor said or I will get a very
tiny letter or maybe nothing.
And if I do get it, it’s only in paper form, because I can’t input it into
my health record, my electronic record, in a format that displays it the
correct way. It’s a mess.
If we get the PCMH or if we get the primary-care home right, it might look
something like this.
So you still have a patient who’s activated. And I just didn’t draw all
those arrows just to make this a little less busy slide, but once activated,
the patient may have all of these issues or concerns. They may bring them down.
They may tell them to me directly. They may put them in a patient health record
or a portable health record to bring in.
My job is to help them sort it, order it, get the right elements down to
really synthesize that. So we’ll call that “directed activation,”
instead of “undirected, unspecific, unsupported activation.”
And then we come up with a shared record, right? We, then, have agreed that
these are the things from what you bring in that we think are the most
important to do.
And then, in turn, when my patients need to move on to specialty-level
care, there needs to be a way to create vetted data subsets that can move back
But the problem in this is me, right? How am I going to do this? Can I
filter all the data? If the patient comes in, am I going to enter all that data
into my record? Am I going to then be able to parse it out to the — I think,
now — seven different insurance-company reporting frameworks that all operate
differently? How am I going to parse all that? How am I going to work with all
that in the time that I have for an encounter?
So the problem is I can’t do this without some help, and I certainly can’t
do it in the constraints that I face in everyday practice when I have different
insurance companies, different formulary benefits, different structures for
reporting and collecting data. So this is an important task, if we get it
So here’s the story — you heard this a little earlier today: Mrs. White’s
55 years old. She comes in to see me this afternoon, and here’s how it’s going
to work in the perfect world, at least close to the perfect world.
She submits from home her reasons for encounter. She’s having fatigue,
nausea. She wants to talk about screening tests. She writes that to me so that
I have an idea of what she wants to talk to me about when she comes in.
When she comes in, my face sheet on my electronic record displays her
current, active health problems. She’s overweight. She has dyslipidemia. Her
current medications. And prompts me that she needs a mammogram, because it
searched and found that she hasn’t had a mammogram in the past year,
year-and-a-half, whatever our screening intervals become.
So we talk. I clarify her symptoms. They go into a record. I have a
decision support routine that uses my PBR, my practice-based research network’s
longitudinal database that looks at the probability of disease given a
presenting complaint, and it says, “Ah, likely diagnoses. Let’s see,
diabetes, thyroid disease,” and it goes down the list and says,
“These are the most important things you might want to think about
And we talk about it, decide to assess the most likely possibility with a
lab test and we do an A1C in the office, and, yes, she’s got diabetes.
So I enter that diagnosis into a record, and that automatically enrolls her
in my practice diabetes registry, which is based upon a clinically-vetted
decision. This patient has diabetes. We know it’s diabetes. It doesn’t have to
come from some billing records that may or may not be accurate.
It sends a notification to her right then with the website email address,
gives her online patient education that we’ve vetted and asks her to schedule a
visit with your practice nurse. And my nurse then can do some diabetic training
sessions without me needing to see her.
She then learns how to self monitor her blood sugars, post results to me
through the secure patient portal. My office staff gets wind of them, sees
them, reviews the records and follows it.
And then, after a while, her glucoses rise like they do, and then I send
her another message that says, “All right. Time to start Metformin.“
Using the portal, we send an electronic prescription in for Metformin.
We’ve done this without several other office visits. We’ve done this fairly
efficiently, and we’ve done it using a team.
At her follow-up, three months later, is the first time I see her face to
face, and we talk. We talk about her goals. The MR prompts me it’s time to do
new diabetic-care measures. So we need to do our foot exam. We need to schedule
her for an eye exam. We need to do the micro-albumin measuring.
It reminds me that her last LDLC was above target range. So we spend a lot
of this time talking about how she’s adapting. We don’t have to do all of that
work because that’s done and we can spend time talking about her treatment
preferences, her goals and how to manage things to meet her needs.
After the visit, she keeps monitoring. She forwards her home glucose
readings for review and adjustment and then sends questions that she has in
through the portal to the practice, and we can answer them. Sometimes, they
might require a visit. Sometimes, they just require that we talk
Because she’s now in the registry, her data get included in the patient
summary reports, and then, every six months, we’ll look it over, within the
And every year, then, we can automatically package up people who have her
particular insurance and send them on to insurance company to say, “Yes,
we’re doing our job. We have done that disease-specific care. Here’s your
disease-specific care measurement.”
So what’s in the way of this? Well, these are the attributes that we just
talked about — OK — and we’ve been talking about them for three days. This is
Klinkman’s view of the core patient-centered medical home attributes, and
they’re like everybody else’s, population-focused.
So for that you need accurate data about who’s in the population, and we
haven’t really talked to you about data accuracy from all our secondary data
sources, but it’s pretty bad. We need identifiably to know who the responsible
clinician or practice is. We have no denominators, and we really don’t have too
many enumerators here.
We need to know — Because this is first contact, we need to be able to
capture data from direct and indirect encounters. We must routinely capture the
reason why people come into see us, because that’s the only way we’re going to
know whether symptoms progress to disease or not and who they progress in.
And so that brings us, then, into the ability to begin to do some
prevention. We also need to know what medical diagnoses they have, but you
gotta remember that a large part of the time, when we’re dealing with problems,
we’re not dealing with diagnoses.
It needs to be patient-centered, which means that we have to have reliable
and up-to-date information about patients’ preferences, goals, satisfaction,
significant life events, all those things that get in the way when I’m seeing
patients or that it’s important to know about and deal with that we can’t
record routinely yet.
It needs to be efficient and effective. Gotta be able to discriminate
between those conditions that require diagnosis and treatment and those
symptoms that don’t. That requires a structure, and we’ll get to the data model
in just a second. Requires clinical decision support capability. All those
things that Chris was talking about in Denmark, they gotta be here.
And, finally, it’s gotta be integrative. You have to be able to
interoperate, because not everyone will ever, in this country — maybe not ever
— have the same electronic health record. You’ve got to be able to move
information from one platform to another.
The red are the gaps, okay? And this comes from somebody who spent years
trying to close a few gaps.
We don’t know denominators. We do have registries. In my office, it was a
year-long struggle to figure out who a responsible clinician was, and we still
don’t agree about this.
So this isn’t all IT. This is just some human stuff here, too, but we don’t
routinely capture reasons for encounter. We can’t separate out symptoms from
diseases. We can’t code social problems, because we don’t have a system for
doing that. All that’s missing. Those are big gaps. We don’t have
What we’ve got, simple, reliable, interoperable. No, that’s not what we’ve
got. That’s what we need. OK? We gotta have this all organized by what I would
consider a fit-for-purpose data model, simple, interoperable, able to be
exchanged, about to not be messed up by getting too complicated.
But what we got are a bunch of standalone, vertically-integrated electronic
health records heavily dependent on clinician data entry. I live that every
day. I hate that, oriented toward diagnosis and billing. That’s what they do.
We heard that yesterday. And, clearly, there’s no underlying data model that’s
fit for primary care in there. OK? So there’s a big gap.
This is a slide that I presented when I was in front of the committee last
fall. This is a data model, a very simple one, that can support the
primary-care, patient-centered medical home.
These are simple building blocks, but when you put them together and use
them, they can capture some complicated things. So you’ve got to know a few
things. You’ve got to know something about the persons, their demographics or
social structure, their goals or preferences. You gotta know something about
problems, how they start, the reasons for a visit, whether they’re active or
not, how severe they are.
You gotta know something about what we call “clinical modifiers,”
and those are things that aren’t yet diseases, but are things that you have to
watch out for, things like prevention. It’s not a disease. We’re trying to make
it one, but it’s not.
It’s risk factors. We manage risk in primary care now about as often as we
manage disease. So we need to know something about how to organize risk factors
and how to incorporate what we’re learning about genomics into patient care.
Gotta know about patient significant events. We’ve got to know something
about actions or processes, and that’s where we have a lot of stuff. We’ve got
CPT. We’ve got coding systems up the wazoo that do things that tell us what
we’ve done. That’s not an issue.
What we don’t have is a good way to describe plans in the future. What is
it that you’re trying to do as a clinician? What is your goal, over time, as a
clinician? What is the patient’s goal? And where are you moving to? What’s the
end point? That, we don’t have.
We also need to incorporate time in the structure. We need to understand
what happens to somebody longitudinally, and that is an episode structure. When
somebody comes in with a complaint or an issue or a problem, what happens to
that problem and how does our understanding of it change over time? Absolutely
critical for primary care. Absolutely critical, I think, if we’re going to know
where somebody is in relation to their goals.
And then, finally, we have to have a way to do data import and export.
Now, here is the crux of it. I can’t do this as an individual actor. I
can’t enter all of this data. I can’t retrieve all of this data, even in a
simplified form. It’s more complex than we can do.
So inputs have to come from everybody. It’s best that the patient or the
person tell us what the reason for the visit is. It’s their words, not mine.
It’s best that they give us what they can about their demographics and social
structure. They could enter this themselves.
It’s good for me to do things like recording the problems, giving the
problems a label or a diagnosis when they become a diagnosis. It’s good for me
to record the actions that I’m responsible for following up on.
But we can also get some help from systems that are already out there.
There are some standards in place now that provide structured data that we can
just swipe into our records, but there’s also some things that can be imported
from other sources. If there’s a rich demographic set of data elements from a
survey, scoop that in.
OK. So the point is this is a distributed system in which the people or the
entities that can put the information best into this record will do so.
Remember, we’re talking ideal here. We’re not talking about my practice.
Now, we talked earlier today about ICPC, this thing called the
International Classification of Primary Care, and that is, in our way of
thinking, probably, and in my work internationally, the best simple framework
to support this model, because many of the elements in this model are already
incorporated in the structure and in the working out of the specific rubrics
for ICPC. ICPC does contain information about persons, problems, processes and
time. The reason for encounter is a core feature of ICPC, and the episode
structure is central to its effective use.
Why it fits? Well, it does episode-of-care structuring. So it tracks
processes of care. It incorporates the patient’s voice. It allows symptom
diagnoses, where appropriate.
It also accommodates social problems in one set of rubrics, so that we can
automatically and routinely record the social problems that effect care.
It is very limited in granularity, although the granularity is well fit to
It is difficult to imagine ICPC functioning on its own in this country in
this environment. So it is not a terminology that we will use as a terminology,
but it is mapped to ICD 9 and 10, and is also being mapped as SNOMED CT, the
primary-care subset that we’re creating for SNOMED CT. And it’s also field
tested. It’s in routine use in countries including Denmark. So Chris has
already got a leg up on us.
Now, a system also has to have outputs, and we’ve talked a lot, and what
we’ve focused a lot on today is the output of this system. What IT supports
primary care and what outputs are going to be useful?
And you can see that a system that does this, even with this basic level of
information, can be very flexible in a whole series of different types of
output that can be brought about from it.
So, at the very top, you’ve got aggregate views, things that we’re doing
now, which is disease registry creation, HEDIS measurement and reporting,
quality assessment in the classical sense that you’ve heard so much about.
But then there are other classes of outputs as well, aggregate longitudinal
views that we just don’t have now.
We can measure the possibility or the probability of a disease, given a
presenting complaint. So if a 35-year-old man comes in complaining of sudden
onset of chest pain, we know that acute cardiac ischemia is not at the top of
the list from real data, not from data after somebody arrives at the emergency
room. We don’t have that without longitudinal data collection, cross-sectional
patient views that will work in the everyday routine practice of the medical
home, longitudinal patient views and some user-defined views that can be
created with, I think, a little bit less overhead with a less complicated
So we’re talking about building blocks. We’re talking about flexible
outputs as an ideal way that you could support a patient-centered medical home.
Can this work with what we have now? Well, this is the wedding-cake diagram.
I think that using the pieces of technology that we currently have, and the
pieces of classification structure that are currently out there, this can be
I think that one way to do it, we ought to look at ICPC as an organizing
structure for a primary-care health-information technology support system that
would be, in turn, mapped to ICD and to some of the ICD family of
classifications, the ICF, which is a functional classification that can be
adapted for use in routine care, the symptom diagnoses that are currently
available in IC — they are limited, but can be broadened — and underneath it
all can lie something as granular as SNOMED at whatever level you want to get
It’s a little bit tricky, but I think that if you want to make a system
that’s interoperable, that needs to communicate specific diagnoses from a
hospital system to a primary-care office, you need to be able to track back and
forth between those systems. It’s just one of those interoperability
requirements, but the tools are in place, and ICPC can provide a structure that
makes it useful in a primary-care medical home.
So summing it up — I’ve talked for a long time, and I talk fast — one way
to think about this is linking the personal health record technology that’s
emerging — You heard Chris talk a bit about getting into that space and IBM
trying to get into that space, and data standards being created for that space,
but think of that as maybe containing some of those data elements that we
really need for medical home, including somebody posting their own health goals
or their own preferences.
In the medical home simple EHR — medical home EHR light, we’ll call it —
may have just very simple structure, an active-problem list, a way to calculate
and manage risk factors, a way to follow problems over time on a very simple
You put them together and you add this wedding cake to try to give the
granularity you might need for some of the interoperability. Now, this is
We didn’t talk about pharmacy, which is easy to do in Denmark, because they
use ATC, which is a fairly easy, lightweight coding system, very hard to do in
the U.S., but it can be done.
There are ways to put these pieces together and to allow components to be
used and to be used relatively efficiently by small practices. Because,
remember, we’re talking about — remember, you just saw that slide earlier —
five percent of practices below a certain size in primary care having
electronic health record now.
So we’ve not solving this with the gold standard EHR. We’re going to have
to solve this with small pieces that work for practice.
With that, I guess I’ll stop and leave time for questions.
DR. STEINWACHS: Mike, thank you very, very much.
Let’s open up for questions and comments to —
DR. KLINKMAN: Oh, I have one more slide. We’ll leave it with — There’s our
recommendations. You need recommendations.
All right. So link PHR TO EHR, organize data into episodes. Use simple
building blocks. David’ll talk more about building blocks later. Building
interoperability and enable practice control of operation. Bottom line.
DR. STEINWACHS: Thank goodness you didn’t leave that off, Mike. So
comments, questions of our panelists?
DR. FRANCIS: I wanted to follow up on some of the privacy questions that
your discussion raised.
In particular, I take it, in Denmark, if you access your record, you can
tell who else has. So, I mean, if I’m a patient and I do that — and that’s
more of a security question, in some respects, but, also, if a patient goes to
see a provider and would rather control where the information in that encounter
goes, the patient has control over that information, maybe with a
break-the-glass feature or whatever. I don’t know. And I wanted to then follow
up and ask whether any of the models that you two were talking about have
either of those features.
MR. NOHRDEN: Yes. I’m assuming that those features are in place, Leslie,
and I don’t know, down at the level of granularity, the specific answers to
those questions. My comments were based on a report that was on our IBM
intranet for employees, given an overview of the Denmark project.
And if we’d like to actually get down another level deeper and know what
specifics go into that security and privacy component, I’d be happy to get that
information for you.
DR. FRANCIS: I’d like it.
MR. NOHRDEN: Great.
MR. REYNOLDS: Marjorie, we heard the presentation from Denmark, and I
thought — at one of our other sessions. Remember we had the nine countries.
MS. GREENBERG: Yes.
MR. REYNOLDS: I think you’re in in Denmark. I don’t think it’s got that
granularity. I’m trying to remember. I thought that was the one country that
basically said, “Your attention, please. You’re in.”
MR. NOHRDEN: No ability to opt out, you’re saying here?
MR. REYNOLDS: I’m just making sure that we don’t leave it on the record. I
think we should research it, because I don’t —
MR. NOHRDEN: Okay.
MR. REYNOLDS: I’m almost sure we heard — I’m trying to remember. We heard
nine or 10 different countries. So we heard all different things, but that’s
the thing I thought was unique. Everybody was in and you were in.
DR. FRANCIS: There are two separate questions. One is whether it’s opt
MR. NOHRDEN: Right.
DR. FRANCIS: And then the other is whether if you’re in, you have some
level of control.
MR. NOHRDEN: Yes, and I’d be happy to get those answers and report those
MR. REYNOLDS: Yes. I just don’t want to leave it like that.
MS. GREENBERG: We can go back and look at the testimony from that hearing,
but, on the other hand, you’d probably have more current information.
MR. NOHRDEN: Okay.
DR. KLINKMAN: Just to quickly respond, I think that part of the personal
health record space is permissions, and so if you are, let’s say, an
adolescent, then I think that you should probably — and, again, I’m not the
ethicist here — have the right to set permissions, who can view your data, who
cannot. “A parent cannot view my data after a certain stage.”
Again, that’s an IT sort of a deal, but it’s also a huge privacy issue that
it just seems logical that that’s the way you’d work it out, but we didn’t
specifically place it in the model.
MR. LAND: I’ll keep wearing my public-health hat, ask a public-health
I didn’t see anything in the model there that relates to the export or
import of information for public-health purposes, and there’s a lot of overlap
there in terms of immunization registries, in terms of cancer registries, in
terms of physicians being called up to see how many cases they have of
influenza that week, bioterrorism events and so forth. Maybe it’s implicit, but
I just didn’t see it explicitly.
DR. KLINKMAN: Yes, it’s sort of a core part of everything.
I think that if you look at it on the input side — I don’t have the input
side up here, but part of the input is immunization input, because that’s been
now probably a 13-year crusade within Michigan is to try to get immunization to
feed into electronic records. We’re finally getting that nut cracked, so that
that data can move. That’s a public-health function.
Likewise, output to public health or output for public-health purposes is
aggregate statistical reporting. So that’s sort of the aggregate views that
you’d see at the very top.
So, yes, it’s just an inherent part, I think, of how we’d see this working
DR. HUNT: And in many models, you see that quality and public-health
reporting are really two faces of that same coin, that if I tell you my rate of
meeting myocardial-infarction measures, that may be the same mechanism that we
get information flows for, say, immunization.
DR. KLINKMAN: That’s one other thing here, too, that — let me just come
back. The whole idea about being able to monitor the prevalence and severity of
social problems that may impact health is a very big public-health issue, and I
think the capacity to follow from the medical home in a realistic kind of
scalable set of codes social problems and how they impact health is a very big
So it’s a missed opportunity in data to date, but it’s a real opportunity
we have here.
DR. CARR: Maybe this is naïve, but are there any models in the U.S.
DR. KLINKMAN: Yes, if you want me to talk for another 45 minutes, yes.
We have worked, at the University of Michigan, on a system that uses ICPC
to do some of the outputs you see on the right-hand side for some time, and we
have had some success.
The technology, actually, has been licensed through our Office of Technical
Transfer to a firm that’s beginning to try to put this in private-practice
offices. It’s now in, I believe, about 150 physicians’ offices across Michigan
that we’re starting to look at implementing it in real-world practices, and, so
far, it seems to be going pretty well. Now, let me qualify that by saying it’s
not this full-data model.
What we did at our own sites is we began with this end — reminding,
reporting disease-specific outcomes to get physician buy-in, so they get some
return on this investment of time.
And we’re bringing it back now to say, “OK. Now, if you want to really
understand more about the process of care and get better decision
support,” we bring it back to coding, reasons for encounter and episodes.
And that’s kind of the tension that you always have here is getting
physicians to a certain point with a carrot and then hitting with the stick.
DR. CARR: A follow-up question. I apologize if I didn’t pick this up when
you — you already said it, but the — so the infrastructure of that first
step, what did that take, in terms of time, as well as political buy-in?
DR. KLINKMAN: You mean for the system as it currently exists in our
DR. CARR: Yes.
DR. KLINKMAN: Well, it took finding money to support the initial
development of the system, which took a period of two or three years. It took a
grant from HCFA to support the initial deployment of the system.
We did a lot of what you heard from Jim earlier about getting people in to
follow work flows. We had an operations engineer who went through the sites and
figured out how every of our five primary-care sites at U of M had different
work flows, although we were supposed to have the same workflows.
And then we brought the system on board to run along citing(ph) electronic
medical record, because we could not get the institution to allow us to
interface directly with the record, until just recently.
So clinicians have actually taken it upon themselves to do this double data
entry for a while, because the value to them of having the prompts, the
reminders, the disease-specific care, the active problem lists were so great.
But it’s — again, you know, it’s a huge amount of activation to get these
things brought into practice when you’re building on top of an already-flawed
DR. CARR: Right.
DR. KLINKMAN: Our best hope might be to work with practices that haven’t
already bought the wrong infrastructure.
DR. CARR: Exactly.
DR. STEINWACHS: Well, there’s still quite a few of them out there, I think,
DR. STEINWACHS: So that’s good news.
PARTICIPANT: We just heard, yes.
DR. STEINWACHS: Okay. I don’t see any other questions or comments right
Why don’t we take a break. We have a humane period of time here, and see
you back at 3:15.
DR. STEINWACHS: Our session is going to be on HIT systems in support of the
primary-care medical home, and we have our first speaker on the phone, so that
we’re into technology.
In this session, we look forward to talking about examples of current
system-support projects, HIT requirements and, as usual, gaps, since it’s a
combination of looking at our strengths and where we need to proceed.
Our first speaker is Dr. David Kibbe, who is Senior Advisor of the American
Academy of Family Physicians, and we were lucky to catch David by phone. He’s
on a tight schedule, and I’m not sure physically where he is, but I’m sure he
can tell us.
David, are you there?
DR. KIBBE: (Off mike) — is that the patient-centered medical home will
only be successful to the extent that the clinically-relevant health
information and data necessary for good clinical decision making are available
to the providers of the medical-home practices.
And notice that I did not say every conceivable existing piece of
information and data, but rather the clinically-relevant sets of information
Now, this may appear obvious, but it is not so easy to achieve, and we know
that better today than we did five years ago.
In today’s fragmented and highly-complicated healthcare environment, more
and more health data are being created, stored, managed and transmitted in
digital or electronic format, and yet we have not assured a level of data
liquidity with respect to the sharing of those stores of data that meet the
requirements of the medical home or that would guarantee access to the patient,
the primary-care doctor or a referral specialist of the needed data in a timely
What we have, in reality, are a rapidly-expanding number of data islands,
whether hospital, pharmacy, clinical lab, nursing home or medical devices, some
of which rather jealously guard the data that they — quote — own, and are
often resistant to requests for electronic transfers.
Now, I think it’s clear that the unavailability of health data too often
supports a business model of healthcare services in which duplication and
rework is a significant component of revenue generation and profit making.
I don’t like this. I think this is bad for the medical-home concept. I
think it’s bad for patients, and I think it’s bad for those who pay the bill.
As a family physician and advocate for a care-management role for doctors
in the medical-home practice, which I’m sure my speaker colleagues have already
elaborated on, I see our role as one of helper and coach, and to perform that
role well in an accountable fashion, I and we need data from our patients’
What we need to assure that data can always find its way to me and my
patients is a set of standards, protocols and methods, including networks, for
health information exchange on the internet that are open, secure and free to
What we do not need is a separate expensive and proprietary national health
information infrastructure or network or NHIN.
And we do need to recognize that business cases and incentives that reward
accountability and resource conservation, rather than duplication and waste,
are part of that picture and go along with those open standards and protocols.
Let me provide you with two examples of the kind of networking standards
that I’m talking about.
Today, at the Tepper(ph) Conference here in Fort Lauderdale, I participated
in a live demonstration which showed how the SureScripts Network, now used
extensively for e-prescribing and electronic exchange of pharmacy and
prescription data between pharmacies and medical practices, can also
accommodate clinical messages in the CTR XML format between providers.
This is, in fact, a natural extension of the SureScripts Network, which is
national, secure, tested and certified.
This demonstration showed how a nurse practitioner at a mini-clinic site
could route the summary health information at the end of a visit to the
patient’s medical-home practice identified by the patient, much the same way
that a refill request is routed now from the pharmacy to the practice.
The entire message shows up as a retail clinic CCR in the same queue within
the doctor’s electronic medical record that is used for pharmacy refill
Once received, the doctor or the nurse in the medical-home practice can
quickly and easily review the reasons for his or her patient’s mini-clinic
visit and review the care that was delivered there.
This particular use of the SureScripts Network could just as easily have
been applied to a medical-home provider sending a CCR summary across the
SureScripts Network to a referral physician with information about the patient,
the diagnoses, the medications the patient is on now and recent laboratory
tests that have been performed.
It could also be used to go the other way around from the referral
specialist back to the primary-care medical home.
And, obviously, one of the benefits here is that this would create an
opportunity for shared health information at very low cost across an existing
network and offer enormous opportunity for continuity of care and continuity of
information that would help us to avoid duplication of tests, avoid duplication
of procedures and so forth.
Again, the value here is not that this is a particular answer to all of our
ills, but it is a particularly cogent, I think, and powerful example of an
incremental approach in which existing technology infrastructure can be used to
support the data requirements, the information-sharing needs of the
The other example I would give you is a little more difficult to describe,
I think in part because we really don’t know all of its ramifications, but I’m
sure everyone in the room is aware of the fact that Google Health Data went
live yesterday, and it is a way for patients to create their medical records
and to control where they go.
I think one of the things that Google has done here is line up a very
impressive number of sources of health information, including PPMs and
pharmacies and some healthcare provider organizations like Beth Israel
Deaconess Hospital in Boston and the Cleveland Clinic, to share this
information with the patient and to allow the information to be aggregated and
therefore made available to the patient and to the providers for that patient.
I think this could have some profound effects in supporting the patient’s
medical-home practice, because of the availability of the information at the
time of care under the control of the patient.
Let me stop there, and see if there are any questions.
Again, I wanted to keep my comments brief today and to this very important
point that we must assure that the primary-care physicians in the medical-home
practices are able to access their patients’ health information in an
affordable manner if the medical home is going to function the way we all hope
DR. STEINWACHS: David, thank you very much.
We’re going to open it up to questions and comments by committee members
and invited guests.
MR. REYNOLDS: Yes. Hey, David.
DR. KIBBE: Hi.
MR. REYNOLDS: The question is you mentioned SureScripts, but that could
probably be done by similar things like the RXHubs and the other things that
are out there doing similar capabilities, right? So it’s not a single solution.
Is that correct?
DR. KIBBE: That’s correct. I think the advantage of the SureScripts are
that it builds upon this e-prescribing capability that — you know — in that
network identifies very clearly who the doctors are, who the pharmacies are,
what electronic medical record systems that they have, and, therefore, it
doesn’t require much additional burden, if any, on those vendors.
DR. STEINWACHS: Other questions, comments?
David, I want to thank you very, very much for joining us. I know you fit us
into a tight schedule, and I hope you have better weather where you are than
we’re having here.
DR. KIBBE: Well, it’s delightful down here, and I’m very pleased I was able
to provide some testimony. Thank you very much for the opportunity.
DR. STEINWACHS: Thank you again. Bye-bye.
Our next presenter is Dr. David Hunt, and so we get lots of work out of our
presenters, you know, one session here, one session there.
Actually, this session, other than Dr. Kibbe, is a repeat performance, but
with new dimensions and new information from our experts here.
David, thank you very much.
DR. HUNT: Thank you.
And I’ll just start where I left off, actually.
As I said, I’d like to pick up where I left off. At that point, we saw a
path forward, certainly not the path forward necessarily, for certified health
systems using interoperable standards across a secure network, albeit with some
But, now, assuming that we’ve reached that state, what are some of the
first population segments that’ll be able to find this a suitable environment,
particularly in terms of a medical home?
Clearly, there’s a natural constituency that can be found with those with
chronic illnesses and stable disabilities.
As the concept of this practice matures, it seems as though many other
segments will be able to find it valuable, and the primary value rests in the
fact that we live in a very different world than physicians at the turn of the
last century. Namely, there’s a tradeoff with the simplicity of before that now
we have complexity that is at times effective, but often very dangerous.
Now, I pointed out just a few moments ago that one tool to improve our
circumstances is health IT, and I also pointed out that that can’t be the
entire toolbox, and if it were, it wouldn’t take us where we need to go,
because I think it’s been stated before pretty convincingly that, to date, we
still haven’t made a convincing value proposition for all of this to physicians
We’ve seen that, even using very liberal definitions of electronic health
record, only 25 percent of physicians have an EHR.
When you limit the questions to those IT functions that are four essential
functions, that still won’t get us to the medical home — namely, electronic
notes, the ability to order labs and medications, and, finally, the capacity to
retrieve lab results. We see that only about 14.8 percent of practices are
using an EHR.
The good news is that that represents a 50-percent increase from 2005.
Still, in small practices, where over half of all care in America is
rendered, we’re not seeing a strong vote of confidence. As you can see, at this
point, adoption is still very heavily weighted toward large practices. But
let’s get back to the question of value proposition to physicians.
Electronic records are expensive to acquire. They take a significant amount
of training to use, and in this nescient IT field, there’s no guarantee that
market forces, buyouts and failure won’t leave a lot of buyers orphaned when
companies — if and when companies go belly up.
Right now, there’s limited interest in interoperability or the ability to
be able to share information, which really speaks, again, to the cultural
values I highlighted earlier.
We currently do not teach, train or reward physicians to provide
coordinated care. So even the best tools in the world will do little to improve
But we are beginning to address some of these problems, certainly not all.
HHS agencies, from CMS to the private sector, are starting to engage, and so we
do have — if we are able to make the requisite cultural changes, what tools
will we have in the pipeline to create that medical home?
If I can, I’d actually just borrow the slides — I was completely — I’m a
complete fan now of Mike’s. I’m going to start his fan club, actually, after
the meeting starts to look again at the patient that he presented earlier and
to try to make some linkage between what we have in terms of the priorities
that have been developed through AHIC and where we can move forward.
You can see, as he pointed out so eloquently, there are a lot of gaps. If
we had the patient that presents — submits her reason for encounter and
arrives with her active problems, that can be fit into the consumer empowerment
use case, and the information flows have been documented as far as that’s
We do not have the ability to actually provide or hook in a strong decision
support, although that is a priority within the office and it’s currently being
stepped up to a large degree.
If you look at the — after entering her diagnosis and enrolling her in the
diabetes registry, we can make the case that the EHR use case that was
presented or that is completed earlier does provide the ability to post the
results to the practice through a secure patient portal, and they are forwarded
to the nurse who reviews the pattern of results.
And the remote monitoring use case, which was developed, I believe, in the
second round, does provide the capacity for the patient — to empower the
patient to actually be a partner in monitoring some of the results and to also
send information in to the different practitioners.
Following up in the face-to-face encounter, every three months — again,
we’re looking at a decisional support piece that should be in place, but we
still have a long way to go. We don’t have the strong use case for that, but we
can see that, again, the remote monitoring and consumer access use cases do
speak to the issues of continuing to monitor her home glucose and actually put
her in — give her access to a summary report, again, to give her access to
this information, and that is the consumer access to patient information that
we had seen earlier.
I think the big bottom line that we can see is that throughout all of this
there are a number of gaps that have been identified, and this is a very, very
particularly appropriate time, because at the very last AHIC meeting, the
American Health Information Community, the group, in recognizing that this is a
transition time, sort of a very important moment in transition time, from the
current AHIC over to the AHIC 2.0, as well as transition time in a number of
other ways in terms of the administration, that we need to take an assessment
of where we are.
And one of the very strong messages that we heard is we need to, instead of
adding more things right now to the pipeline of use cases, which is still very,
very needed, we need to fill in some of those gaps, because it has all of the
features of building three homes each of which have three walls. You need to
finish one of these houses and then move on.
And that actually is the work that we’ve set about to do, and, hopefully,
within the next AHIC meeting, which is scheduled, currently, for June
3rd, I believe, you’ll be able to see some of the results of what
we’ve been able to do to identify those gaps.
And Dr. Koladner will provide some messaging as far as what the path
forward will be to fill some of those.
And with that, I’ll stop right here.
DR. STEINWACHS: David, thank you very much.
Are there any immediate questions to David?
DR. FRANCIS: I actually had one. If you can flip back a couple of slides,
the money per practice wasn’t — there was a —
DR. STEINWACHS: Leslie, I thought you were supposed to stick with ethical
issues, and —
DR. FRANCIS: Well —
DR. STEINWACHS: — money. That’s Nancy’s area.
DR. FRANCIS: There’s a typo and it didn’t make sense.
DR. BREEN: There was a comma instead of a period.
DR. FRANCIS: Well, that’s what I wanted to know.
DR. BREEN: There was 20,00.
DR. FRANCIS: I wanted to know whether there was a zero missing or a comma.
I assumed it was a zero missing. Thanks. Yes.
DR. HUNT: Thank you very much.
DR. FRANCIS: Thanks.
DR. STEINWACHS: Leslie, thank you. I’m sorry. I’m sorry I suggested that
you were in the wrong domain here and that Nancy, the economist, should have
DR. HUNT: — rush to market, I believe —
DR. STEINWACHS: And we appreciate your effort to rush to market —
DR. FRANCIS: Actually — Hey, actually, it’s the lawyer piece of me,
because, you know, you have to do all this copy work when you’re in law school.
DR. STEINWACHS: Oh. Well trained.
DR. FRANCIS: Proofread.
DR. STEINWACHS: I’d like to welcome back Dr. Terry McGeeney, who we heard
from before, who is CEO of TransforMED, and leading the effort in the
family-practice community to develop and demonstrate the medical home.
DR. MC GEENEY: We had a conference call on Friday to kind of — some day
last week — kind of plan what we were talking about, and I realized I’m
sandwiched by two very smart people on this issue. So this will be dummied down
a little bit and in the dirt, in the sandbox.
So what I kind of wanted to do was to get at kind of a granular level what
are really some of the issues for primary-care practices around health
information technology issues.
And I’m just going to go through about five or six things, and you’ve heard
them all before. This is not new information, but did want to talk about it a
little bit, because these are all critically important to primary care.
And it has been said many times health information technology is not the
ultimate goal, is not the end-all. It is a tool, but it is a
critically-important tool if we’re going to move things forward, because, as
Michael said earlier, you just can’t manage all the data anymore. You just
can’t manage everything and take care of patients at the same time.
So one that we just heard about, interoperability, it is a major
vulnerability as we move forward.
Information must be allowed to move freely and move securely, and, right
now, neither are occurring.
Many times, from the — point of view, I think there’s plenty of examples
Something that was skipped over lightly a little bit ago, you know, it’s
not unusual, in this electronic health record world, for a practice to have to
pay $10,000 or more for a data dump or a data run to find out who the diabetics
are in their practice.
This is closely-held information by the technology vendors and the EMR
companies and they’re not going to want to give this up freely, but they
It’s not, in many cases, the practice’s information. It’s not the
medical-home’s information. It’s not the patient’s information. It’s the
electronic health record company’s information, and practices have to pay to
access it, each time, and it’s a major, major issue.
The other thing is secure. I mean, we have a lot of doctors out there that
are sending emails to their patients and talking about an awfully lot of things
on Yahoo.com that they shouldn’t be, and security is a real issue.
The other issue is the — as has been mentioned — the legacy systems in
There is a tremendous sucking sound somewhere between hospitals and
practices where information does not move freely, even when you’re looking at
data registries to self populate, when you miss all the data that’s in the
hospital — Geisinger doesn’t have this problem — to where you can capture the
patient who had an elevated blood sugar in the hospital, that’s not real world,
quite honestly, and when you’re missing part of the data, data is pretty much
worthless, and so I think that interoperability is a major, major issue.
The secure messaging, again. Patients and providers do need to be able to
I mentioned yesterday that there’s a real issue around patient acceptance.
We, in our demonstration project, have ability to communicate
electronically in most all of our practices via a scripted encounter that
integrates into the electronic health record or creates a paper record of that
transaction, that communication, but patients’ acceptance has been really,
really slow, and I’m not sure why that is, but I think we do need to figure
Some practices have even gone to scheduling e-visits as a return visit
instead of having the patient come back, using formats for sharing blood sugars
— all those different things, but that’s an issue.
Concerns about confidentiality are still a major issue, both from the
practice side and the patient side.
And then, lastly, documentation and EMR integration. I think the worst that
can happen is if a doctor starts communicating with their patients on their
palm pilots and prescribing and advising, and none of that ever gets into the
electronic health record, and that’s a very real possibility with the world we
currently live in.
Something that hasn’t been talked about today, but I think is important is
real-time payer information.
One of the issues with practices and the horrendous lack of efficiency in
practices are that you really don’t know, from a practice level, when and what
care you can give. It varies by all the different providers, and it creates a
— payers, I meant to say — and it creates a real problem for providers.
When the patient comes in, you don’t know that their health plan’s going to
cover. You don’t know when it’s going to cover it, and by the time you
communicate multiple times with the payer, often do something, then find out
it’s not paid for, it becomes a real problem.
You know, I still see patients one day a week, and it’s — at the
University of Kansas — and it’s just appalling. What’s the preferred drug for
one company isn’t the preferred drug for three other companies. They’ll all
have different ones.
And in Medicaid in Kansas, they chose the most expensive one. Blows my
mind, but they did. You know, you think you’re going to prescribe a generic.
They don’t cover generic Prilosec for acid. They cover the most expensive,
Protonix, you know? And if the patient wants to get a generic at Wal-Mart, they
can’t, you know? And just stuff that’s counter intuitive.
One company wants one thing before you can do an MRI. Another — And that
is an exasperating situation to a practice.
And technology can offer a solution by integrating into an EMR real-time
basis or in some way providing what can and will be paid for.
But then there’s also the real-time coverage information when you’re
talking about copays, deductibles, whether the patient has insurance. These
become very, very labor-intensive things for practices that you would think
would not be that hard that when the patient comes in, you know what’s covered,
what isn’t and what they have to pay for when they’re there, but that would be
quite a dream situation for a practice.
And then, as I said, the copay and deductible information.
The challenge is that there really is a major inability to access
information real time, and there’s a major reluctance of payers to share that
information real time.
Six weeks later, after they’ve held your money for six weeks, they’re more
than happy to do, but real time is a real problem.
And, you know, we’ve been working just trying to know what a patient owes
at the time they’re there and collect that.
We’ve got information that costs $7 to $10 every time a practice sends out
a bill, and if you have to send out three bills for the $10 copay in a
primary-care practice that has a very narrow margin, that’s an issue, and
technology can be at least a partial solution to that.
Population-based registries. You’ve heard a lot about that, and it really
is a critically-important factor to providing chronic-disease management.
Patient-centered medical homes need the ability to have point-of-care
reminders. That’s been mentioned several times today. They need to have
evidence-based best-practice reminders and information, and they need to be
able to manage populations of patients proactively.
As you heard earlier today with the Geisinger presentation you’ll hear more
about later, to be able to identify your diabetics by who had an elevated blood
sugar when they were pregnant or who had an elevated blood sugar when they were
in the emergency room or in the hospital, that’s identifying that patient when
they’ve got a blood sugar of 130, not when they show up three years later with
a blood sugar of 500 and are losing their vision, and that’s what registries do
They also, as we talked yesterday, allow you to know in your practice who
all the patients are with a certain issue and be able to manage those patients.
The three-thousand patients that don’t come in, you give them the
opportunity to come in. You give them the opportunity for education, and you
don’t just wait until they show up or hope to show up.
It’s not unrealistic in this day and age — Paul Grundy(ph) from IBM was
giving a talk one day, and, as a purchaser of healthcare, he told the practice,
“I want to be able to call you and I want to know which of my patients
over the age of 50 need a colonoscopy, and I want to know while I’m still on
the phone.” Not impossible with today’s technology.
But the challenges are, again, the lack of interoperability between labs,
EMRs and hospital systems and registry systems.
There’s getting to be a number of registry systems out there now, and
they’re going down the same path as EMR systems, keeping secrets, not
interoperable, not transferable from one to another, not integrating with EMRs
without paying them each time.
And so we’re heading down the same road with the new technology, because
they realize there’s a lot of money to be made. And then the reluctance of the
owners of data to provide access to the data.
In our demonstration project, we’ve been working with vendors around the
country to be able to build population-based registries on the back of EMRs
that don’t have a registry function. Seems like a good thing to do.
It has been extremely difficult to get EMRs to give us the information to
be able to build the connectors for reasons that, many times, I still can’t
We’ve been able to do it, but it’s been a lot of personal phone calls, arm
twisting, you know, under the guise of the demonstration project, all that kind
of thing, but there’s no reason that — even the technology exists to be able
to build the connectors. The EMRs won’t allow those connectors to be built, and
so it’s a real issue.
Automatic reminders. Again, it was brought up earlier today, but it’s
important. Practices need to be able to automatically remind patients of issues
that directly affect their health and well being. Somebody said earlier their
veterinary does it for their pets.
My son bought a house. Their realtor sends reminders every month to change
the air filters on the furnace, but yet we can’t remind our patient that they
need a Pap smear or a mammogram, and there is absolutely no reason. The
technology exists. It’s out there.
The other thing that was talked about and mentioned earlier that’s worth
reminding everybody of is you can do most of this without an EMR.
The technology exists to integrate the billing system with the lab systems,
and even the technology exists to roll in payer debt, so that if you did a
colonoscopy, you can know if Blue Cross Blue Shield got a bill from a
colonoscopy for somebody else. So even if the practice doesn’t have an EMR, you
can really build a pretty vibrant registry and get about 80 percent of what you
need to do, and we need to move that along.
Also, so you gotta remind the patients, and that technology exists. The
technology exists to scan when you tell a patient to come back and they don’t.
The technology exists when a high lab value comes back and it wasn’t acted on.
So it’s not only reminding the patients, but it’s reminding the provider.
As I said a minute ago, there’s so much going on in offices anymore and so
many things to think about and so many recommendations that what ends up
happening is most of them get missed, and less than 50 percent of the time, we
provide the care that we’re supposed to provide.
If, when that patient comes in for a sore throat, they’re reminded that the
patient’s also due for a tetanus shot or a mammogram, it becomes very, very
easy to do and something nursing staff can do.
Without that, the provider is not going to wade back through the chart —
they’re just not going to — and figure out these things.
But the challenges, again, are lack of interoperability, the lack of
understanding of best-practice standards and then the lack of office processes
to really act on the real-time recommendations.
What we try to work with in practices is, again — it’s the team concept.
Most of this stuff does not have to be done by the providers. It can be done by
the nurse, when the patient checks in and a lot of other people that are part
of the team. But the automatic reminders are another thing that can be very,
very important for practices.
We’ve heard a lot about portals and patient portals, and David just
mentioned Google a few minutes ago. The patients need ready access to their
records. They need ready access to health information that’s reliable. I don’t
think anybody argues with that.
The patients need ownership of their information. The patients also need
ready access to a provider, be it making an appointment on line, talking to
their provider on line or just getting information from the office, but we have
the same things, the challenges are ownership.
I can tell you right now that you can be a patient portal and you can sign
on to any of a number of insurance companies, you can sign on to employers, you
can sign on to Google. You’ll be able to sign on to Yahoo. You can sign on to
Practices are not going to do that. They’re not going to sign on and log on
to eight or 10 different sites to try to find the patient’s portal.
If the patient-portal concept is going to be successful, it must be based
on the patient-centered medical home. That practice that’s the patient-centered
medical home is where the patient portal needs to live.
Now, there’s a lot of other ways that companies could join, but to have all
these separate sites just is not going to work. But, again, that’s what we’re
seeing happening right now is all these patient portal sites, and practices are
just not going to be going to multiple sites.
Confidentiality becomes an issue. Security becomes an issue, and something
I didn’t add to the slide that I should have is accuracy becomes an issue.
We talk a lot about patients entering their own information on to the
patient portal sites, but accuracy has become an issue when you start looking
at patient-entered data, and just something we need to factor in.
So final thought, if primary-care practices are to successfully transform
the patient-centered medical homes, health information technology must also
It’s not that health information technology is a critical success factor.
It’s not even where it needs to be, but we must — need to transform in
Then I shared this. This is the screen saver on my laptop, and it reminds
me time and again how far we have to go and how much work we have to do.
It’s one thing to sit in a room of people like you today that are very in
tune to these things, but this is really where a lot of the world still is,
unfortunately, and so I keep that on my screen saver to keep reminding me of
And, with that, I’ll stop and thank you.
DR. STEINWACHS: Terry, thank you very, very much. Any specific questions
for Terry at this point? Or we can move on to the next speaker.
Nancy and then Larry.
DR. BREEN: There’s been a lot of talk about population-based registries,
and, as I understand them, you’d be putting the patient population into, I
guess, a condition or disease or something based place, so that you could
retrieve the data by some kind of diagnosis or code or something.
But to really be population-based, it’s going to have to be bigger than a
single practice. How would that work? How would the information be put into a
bigger place, so that you had it for a town or a metropolitan area or a state
or a nation?
DR. MC GEENEY: Funny you should ask. What we have been doing — Right now,
the population is — referred to the population of patients in a practice.
Well, the next step we’ve done is we have the population of patients in our
TransferMed demonstration project.
Actually, the American Academy of Family Physicians was mandated by their
Congress of Delegates last year to develop some sort of a clinical data
repository for patients of family physicians across the country, and so that’s
the next step.
Of course, now, we’re getting all the vendors starting to play again, but,
realistically, it’s not that hard to have any one of a number of vendor
registries, whether it’s from EMR or free standing, to put data into a central
repository that can then be pulled out, and, all of a sudden, you start getting
a number of patients that’s meaningful. And we’re just doing that for our
specialties, as much as anything, trying to drive the market. There may be
another way to do that.
There’s some work being done in Oklahoma that they’re thinking about doing
it countywide to start looking at populations of patients in a given county,
and so it’s a fairly new area, but I think it’s going to go from practice to
project to county.
It’s starting to be looked at at state levels, certainly within some
Medicaid systems would be totally doable. With a lot of pilots, we’re going to
get involved in across the country, we’re really, really pushing the idea of a
project-wide registry, because I think that’s where we’re really going to get a
lot of learning around these pilots, but there’s a lot of conversation about
that right now.
DR. STEINWACHS: David, did you want to add to that?
DR. HUNT: And, actually, a derivative of that is the concept behind the
chartered value exchanges, local communities that actually share quality and
value information to help, hopefully, inform the consumers and other payers and
employees as far as the value of the services given within a community.
DR. GREEN: Terry, if I recall correctly, yesterday, you mentioned that out
of the demonstration that you felt like you had a practice that sort of got
DR. MC GEENEY: We had — when I made that slide, we had a practice that had
done every aspect of the patient-centered medical home. We have active
population-based registries in over half of our practices.
DR. GREEN: Well, just thinking about that practice is what I want to ask
you a question about.
Today, I found there’s a recurrent message that’s come through virtually
all of our sessions, and it is that profit incentives create perverse effects
that are compromising the public good.
How did that practice do it?
PARTICIPANT: What was your question?
PARTICIPANT: Where are we?
DR. GREEN: How did that practice manage to get that far in the environment
we keep hearing about today?
Now, you know, my slide, when it all went red — you know, heart-sink
moment, you know. Look at all the red up there.
We keep hearing that there are these perverse incentives, that people who
have the data want to sell the data and keep the data proprietary and that
that’s — we’ve heard, in our discussions about interoperability and the
quality group — forever.
But I think you’re telling us that, despite all of that and despite your
list of challenges, that you’ve got some practices that are getting close.
DR. MC GEENEY: We have several practices, now, that have implemented all of
the components, and we have all but one of the practices that either have
implemented or will have implemented in another month a population-based
registry on the back of their EMR. None of the EMRs had them. It took an
awfully lot arm twisting, but it is doable.
DR. STEINWACHS: Why don’t we move on?
Pleasure to have Dr. Jim Walker back again, wearing another hat. No, it’s
the same hat, but another related topic, as Chief Health Information Officer
for Geisinger. Jim.
DR. WALKER: Thank you.
Someone asked, advanced medical home is what our community practice service
line calls this. It doesn’t have any particular meaning beyond that. So you
know about us.
DR. STEINWACHS: Jim, you didn’t change the 14 clinics.
DR. WALKER: No, I didn’t change it.
I want to talk about four things — four large headings: The goal of health
information technology, end-to-end care processes, precisely-informed actors
and transparent reporting.
So my latest version of the goal of health information technology is to
support the flawless performance of a PCP and patient-led virtual team that
manages all of a patient’s health needs and information across every setting of
care, and, obviously, across the life span.
And that means that when we get to this point, we will have achieved
something larger than any of the topics we’ve been talking about today —
primary care, chronic disease management or even medical home.
The reality, of course, is quite different and doesn’t need to be talked
about too much.
So the second thing I want to talk about is end-to-end care processes. It
seems to us that this is where we need to get to, where we understand the
process of care all the way from population-based screening to end-of-life care
for multiple diseases, and all of those processes run end to end, and people
can tell what’s going on at any point in that process for every patient.
And to do that, of course, we have to have end-to-end health information
technology, and, as you’ve heard, we have nothing like that at the present.
Although, in many ways, we’re getting closer — Well, I can never remember. It
wasn’t Muggeridge, I don’t think, who said that the future is already here. It
just isn’t evenly distributed. So what we’re trying to do is get the future a
little more evenly distributed.
First thing I want to talk about is the actors. We’re trying very hard to
broaden the view of who the healthcare team is.
We have been prone to say, “Well, it’s dumb to have the doctor do
that, because he’s too busy and he won’t remember it anyway. So we’ll have the
nurse do it.”
That is a little less dumb than having the doctor do it, but not a great
deal less, and certainly not fundamentally.
What we want to do is have a whole set of actors for whom we understand
what their most effective role is, what kinds of things they can and must do,
depending on what it is, and make sure that all of them are really built in to
all of the processes, so that they get the information they need at the right
in the right form for them to take their action.
And they don’t have to worry — none of them have to know or worry about
what the whole state of the process is. All they have to know is either it’s
time for me to do something or it isn’t time for me to do something. So what
does end-to-end HIT look like? The first thing is an automatic identification
of patient needs and care plan status.
We are doing population screening and risk stratification. We’ve done it in
a number of forms. We have sent patients invitations to do it on line and put
in their risk factors for coronary disease, see what their risk of having a
heart attack in the next five years is and then play with a little device that
lets them say, “Well, if I controlled my blood pressure, what would that
do to my risk?” “If I quit smoking, what would that do to my
Let them say, “Okay. This is the set of things that I think I’d be
willing to do to address this risk,” feed that into the EHR, and, of
course, schedule a visit for the patient, so that when the physician sees the
patient they can see what the patient has thought they would like to do and
start the negotiation at that point, and then we’ll talk about what happens
Care reminders go directly to patients in the electronic health records.
“It’s time for your annual mammogram.” “It’s time for your
Hemoglobin A1C,” with a reminder about how to get it done. So all I have
to do is show up at the lab or the appropriate place and get it done. Those
care reminders also come to physicians and nurses and other professional
For the most part, if they come to them, it means that the system has
already failed somewhere upstream, but they are there.
And then we have disease-specific patient summaries, both for clinicians
and for patients, to sum up where the patient is in terms of their management
of their diabetes, what needs to be done, where they are with respect to the
goals they’ve set for themselves, that sort of thing. And, as I say, that’s for
both. They obviously take different forms for the two different audiences.
Automate patient engagement. You’ve noticed the frequent use of the word
“automate.” We don’t believe everything can be automated. We think
some things should not be automated, but many things can, and we want to know
what can and what cannot be effectively and automate everything that can be.
Personalized invitations to care. Personalized updates at checkout, so that
patients are invited to fill out questionnaires before they come to a visit, so
that they already have put in some of the information that’s going to need to
be elicited for that visit.
They also — the thing that they like, actually, is that they can take care
of their insurance data, so they don’t have to stand there while the clerk asks
them, “Do you still live at this address? And what is your
insurance,” and all of that sort of thing.
And then at checkout, the patient automatically gets a printout of tests
that they’ve agreed with the doctor they’re going to get done and instructions
about anything that needs to be done and reminders, and the medicines that have
been stopped at this visit and the resulting new medication list. All of that
is provided — printed for the patient automatically at discharge.
Standardized clinic processes. The team that does this has just done a
superb job of creating a whole set of electronic tools that guide — that
provide reminders for nurses — patients.
You saw we’ve gone to 88 percent of obesity screening. All that means is
that the nurse gets the patient weighed 88 percent of visits, and the EHR
converts that into a BMR and a set of recommendations about education and so
forth, treatment, so forth.
We have protocol-based order sets, which I’ll show you in a minute, but the
idea is that for diabetes, for instance, once the patient and I negotiate their
care plan, there are multiple order sets, and I can pick one that fits the
patient, select the things that are appropriate and then dial in that this
patient needs their Hemoglobin A1C every six months, this one needs it every
three months, and all of that is dialed into the system.
And then the patient gets automatic reminders when it’s time for that to be
done, doesn’t have to hear anything from the physician office and doesn’t have
to come to the physician office. She just comes to the lab sometime when it’s
convenient, gets the test done and gets the letter back from the physician with
the results, or, actually, electronic signal for the ones on patient health
record. Med reconciliation, the same thing.
The exciting thing there is that because we have inpatient and outpatient
integrated, if one of our patients is admitted — one of our outpatients is
admitted to the hospital, when they’re admitted, the nurse, doctor, the
multiple people who admit the patient, see their outpatient med list and can
actually click buttons to say, “Hold this one. Convert this one to IV.
Continue this one as is for the inpatient stay.” So that they can order
new medicines being — well, confident that they know the med list because
they’ve asked the patient, “Is this really your med list?”
And then when the patient is discharged, the discharging physician sees the
inpatient meds along with all of the meds the patient was on at home before
they came to the hospital, and, from that list, again, just clicks buttons and
says, “Continue this one. Stop this one. Continue this one, and, by the
way, put a note in for the primary-care doc, we stopped the Licentapro(ph)
because their potassium went way high, so we’re going to try them on an
So that then the patient leaves the hospital with a printed list.
“These are the ones we stopped. This is your new med list,” and all
of that goes electronically on discharge to the outpatient doctor.
If they’re a Geisinger doctor, it goes electronically. If they’re a
non-Geisinger doc, it goes via fax or if the doc, for some reason, prefers
snail mail, we’ll send it that way, too.
Automate remediation of suboptimal care. So, again, an alert is the last
refuge of a scoundrel. It means that a process hasn’t worked for some reason.
So we’re trying to catch it before it gets any worse, but we do have a number
of EHR alerts, and then standardized order sets that are linked to those
alerts, so that if something does become overdue, it’s easy to see that it’s
overdue, check what’s happened and then pick an order set that you can order
what you need. Continuously optimized HIT.
We had a series of very serious meetings, very doleful meetings when we
were nearing the end of the outpatient implementation, and we had this
phenomenal team built up that implemented 43 separate clinics in the last 12
months of the implementation.
So this is terrible. We’ve got this high-performance team, and now they’re
going to have nothing to do, and we were really trying to figure out, you know,
help them find new jobs or whatever.
And, as I told you, what happened is we have so many process improvement,
EHR improvement, and, for us, the two become just two sides of one thing,
projects, now, that we cannot keep up with all of them, and we have more people
on the team than we had when we had those doleful meetings.
So, first, preimplementation process redesign, we think is critical. My
estimate would be that the bulk of failures — of outright failures and then
the failures where they use it 20 percent of the time are because this step
isn’t done, and the tool simply does not fit the mental models of the people
trying to use it. It doesn’t fit the workflows that they use, and so they do
the natural thing, which is to ignore it.
Continuous optimization turns out to be the surprise. We had no idea about
this. It’s incredibly powerful, and in clinics that have been live 10 years, it
is still an ongoing high-speed activity.
There are still all kinds of opportunities, as all of you can imagine, to
improve our workflows, to improve the training of our clinicians, to improve
the way the EHR supports those two things, and so all of those are important to
us in terms of making sure that we’re really optimizing them.
So that, for instance, we are working — we haven’t gotten it done yet, but
we have a learning management system that will actually allow us to assign
curricula to nurses and doctors and front-desk people and call-center personnel
and nurse educators and be able to track automatically when they have completed
those online curricula, so that we can confirm that everyone in our system
really knows how to use the EHR and make it a tool that sings instead of
something to beat you over the head too many hours a day.
Every loop closed. Why is it when you’re given a new medicine, a new
prescription by your doctor, why is it that the office doesn’t call you or send
you a letter in four days and ask you if you’ve gotten it filled and if you had
any of the side effects that happen more often than placebo in randomized
controlled trials? Is there a reason they don’t do that?
You realize there are 190,000 hospitalizations a year because of adverse
effects due to new outpatient prescriptions that were not caught and dealt
with, and almost 70-80 percent of them could have been ameliorated if they had
been identified quickly enough and/or the receiving person had known what to do
So there’s a whole set of loops that aren’t closed. Test results. Do we
know how many of our mammograms haven’t been done within one month? And what
percentage of abnormal mammograms the patient is contacted by the breast clinic
within 24 hours of the filing of the result? We don’t. When I come back next
year, we will.
There’s a whole set of loops that we need to close that it is not feasible
And back to the first question, the reason your doctor’s office doesn’t
call you is because there isn’t enough money in the world to do that.
With a robust EHR — and most are not robust — but with a robust EHR, it
becomes just a little more work at setup, not a whole new project that is so
expensive that it doesn’t get done. I’m going to talk about discharges a little
later. Precisely-informed actors. Talked about this some.
The first thing is data capture. If you have new onset low back pain, there
are 18 questions the doctor needs to answer. If the answer to all of them is
no, you don’t need an X-ray. You don’t need any medicine, unless you want to
take something for pain. You don’t need physical therapy, and there’s a
90-percent chance you’ll be entirely — essentially well in four weeks.
On the other hand, if the answer to one of two questions is yes, you need
emergency MRI and emergency X-ray therapy consults, because there’s a
96-percent chance you have metastatic cancer.
Can your doctor remember those 18 things? No. Any of the doctors in this
room will be glad to confirm for you that they can’t.
But this is something I typed: .LBP, low back pain, and that pops up on the
screen, and I read it to the patient, and I say, “Do you have any blah,
blah, blah, blah, blah, blah, blah,” the ones that I don’t know. And then
I examine them and answer that second set of questions, and there’s a little
note in the text that says, “If all these answers are no, you don’t need
to do anything, except reassure the patient, if these take care of this.”
We aren’t to the point yet that we’ve built this into a patient
questionnaire, but we are doing patient questionnaires in the patient history,
and this is one of the things that’s obviously one of the things we’ve gotta
transact is if a patient says, “I need to be seen for low back pain,”
they ought to answer those questions in blue before they ever get to the
And, by the way, if they answer the first one yes, they shouldn’t come to
their primary-care physician. They should go straight to the MRI scanner and to
the XRT consultant.
One of the ways in which what we really want to create is a virtual medical
home where the primary-care physician doesn’t even know that that’s happened
until after the fact, but the patient gets care as good as if the primary-care
physician had nothing on earth to do except take care of them.
Lot of tools we build to make this kind of performance possible. This is
pre-admit evaluation for care management. This is a tool in production that
care managers use when a patient is admitted and they ask things like,
“What kind of caregiver arrangements are you going to need?”
“What kind of social support do you have?” So it’s preparation for
discharge when the patient is admitted.
Surgical-risk evaluation. There are tools that enable us to say,
“You’re at 15-plus percent chance of having a serious cardiac complication
as a result of this surgery. So we’re going to watch you like a hawk.”
“And you’re at zero-percent chance. So we’re still going to watch you
carefully, but we’re not going to put you in the monitored unit,” because
it only has so many beds.
Again, in production, being filled out on all of our surgical — well, most
of our surgical patients, social services needs evaluation. The same thing.
What’s this patient going to need when they go home? This is one that social
workers use to systematically assess patient needs, make sure that we get those
needs dialed into the system so the patient gets what they need fast.
Same thing with the nurse discharge checklist. Same thing with the
physician discharge checklist.
So that all of the team gets the information they need, gets the
opportunity to document what they’ve done really rapidly, so that everybody
else can see, in real time, what’s been done and what needs to be done for this
patient to be ready to go home.
And, of course, most of this, is done, ideally, and often, in fact, well
before discharge, more than 24 hours before discharge.
This is post-discharge. One of the things that we’re trying to do is manage
transitions of care better, and so this is an alert that would go to a case
manager, say, “This patient was discharged from the hospital and doesn’t
appear to have an appointment for follow-up schedule.” And the case
manager can document what they were discharged from and get that moving.
Data movement is a big problem. Obviously, internally, we don’t have as
much of a problem, but we share lots of care with non-Geisinger physicians and
So how does that pan out in real life? Well, there are scanned documents
that — We have high-speed scanners. They are linkable to lab results or other
categories in the EHR. We can link them to a patient. We can link them to a
hospitalization. We can link them to a visit, and those are scanned into the
record, so that they’re there when somebody needs them.
Now, in fact, probably a lot more scanned than ever looked at, but some are
looked at. Hand entry is a painful, but very useful thing for us to do. So if
we’re going to pay physicians for patient Hemoglobin A1Cs less than seven —
and lots of them go to the VA because the Hemoglobin A1C costs less at the VA
— we have to get that Hemoglobin A1C result into our system.
What we’ve done is create a centralized activity where skilled data
enterers receive this information from clinics who have identified that this
one is big enough a deal — actually, policies that identify which ones are big
enough a deal that we’re willing to pay this much money to get them entered
into the electronic record as — I mean, it’s a very — expensive form of
interoperability, so that they actually interoperate in our system. We can run
alerts and payment schemes and registries and everything else off of them.
And then we do have a regional health information exchange where we’re
starting to do a number of things, all the way from EHR access, so that in
emergency rooms the doctors can simply see from the master-patient index that
the patient was taken care of in another facility and look in that other
facility’s EHR all under incredibly careful HIPAA control.
Scanned documents is actually going to be a large part of this. We think it
will be — We just signed the contract for this, so we’re just starting it, but
we think it will be a large patient satisfier.
One of the things this means is that discharge summaries and other very
high-value documents like that will be in this repository that’ll be available
around the region for providers.
We also are going to offer it to patients as an opportunity to create a
patient health record that has the virtue that whoever looks at it will
actually be able to see where the data came from.
One of the problems with the patient health record that you’re aware of is
that patient says, “I had a Creatinine of 2.3 in California two years
ago.” That’s valuable information, but it would be more valuable if I
actually could see the result, either some kind of electronic tag, or, in the
real world, the paper printout from that lab, so I really know what that
Creatinine was exactly when and I can put it in REHR, so then we can track
their renal function.
And then, finally, we actually do have one hospital that is feeding —
well, two hospitals that have translated their lab results into LOINC and are
feeding those into each other’s electronic health records and are available
Data presentation. Real patients that come to at least our practices over
and over again have lots of problems, complex problems, and it’s hard to know
in any current system which parts of their care is on track on time and which
And so we’re working on new methods of presenting data — this is a problem
list, an optimized problem list that doesn’t exist anywhere except in my head
— that would enable a clinician very rapidly to see, “Oh, OK. Green means
go. Everything’s fine. Yellow, something’s wrong there. Something needs to be
done for hypertension, and CHF, something needs to be done and it needs to be
And simply double click on that and see what it is that makes that an
actionable item for the patient, so that we’re working on making data
presentations that make it clear at a glance where the attention needs to be
focused and then make it easy to focus attention there.
Action support. We have diagnoses listed automatically to care plan, so
that diabetes has multiple care plans. It can be selected and adapted for the
patient, order sets that are linked to those diagnoses and care plans and then
patient instructions that are linked to those order sets. So that if a patient
has diabetes, all of those things flow together for the provider, and some of
them may have even been teed up by the person that roomed the patient. So that
it makes it easy to cover all of those activities just by getting the right
diagnosis in the problem list.
This is a training document. This isn’t an electronic document, but the
blue is an order set and has checkable orders. And if you could read it, you’d
be able to see some of those are meds, some are for labs, some are for
follow-up, some are for instruction. It’s the whole set of — some are for
printable instructions for the patient to take home with them, all of the
different things that would help the patient and others to take good care of
the patient all in one compact easy source.
And then down below at the very bottom of that, you can just see the top of
the letter that is going to go to the patient as a result, dynamically, of the
things that are ordered in that order set, ideally, after discussion with the
patient of what they want to do.
We have prefilled refill referrals, so that we are — the chronic kidney
failure is one and the coronary artery disease is another and the diabetes is
another. So we have trigger points when care becomes more complex than is
generally appropriate for primary care, although, we don’t try to tell doctors.
Some primary-care physicians do more of some things and some do less, but
when it reaches that threshold, then there are prefilled referrals that carry
with them automatically the information about the patient, and that’s whether
the referral is to inside Geisinger or outside, and make it easier for that
referring doctor to know where the process is, what the information about the
patient is and what the question that they’re asked to answer is, and then, of
course, they have tools that make it easier for them to reply back and say,
“Here’s the plan. I’ll take care of the Amiodarone if you’ll push the
Same thing. Direct-to-patient reminders linked to self scheduling.
One of the reasons the no-show rate drops to 2.1 percent is because we
provide the patient reminders of when they’re visit is.
The patient — Well, have to call this something different. Whatever this
is. What we call a patient health record. I told you about it. It does all
It is used actively by case managers to communicate with patients as well
as physician practices. Some of those case managers are embedded in practices,
some work more virtually. It enables patients to do secure e-messaging and lets
them do all of these sort of self care things for themselves.
A number of people have talked about the flood of information that’s being
created, and the particular flood that scares me the most is the idea of a
patient having multiple patient health records and bringing them all to their
doctor and expecting their doctor somehow to look at them and process them and
act on them and keep a record of what they’ve done and so forth.
And so what we are just starting to build is a data-response center — and
I have a better name for it. Sorry — because there’s this flood of lab
results, got all those abnormal mammograms, not to mention the normal ones. You
have all kinds of patient input. We have patients filling out a paper version
of a depression scale in waiting rooms and then that’s scanned and turned into
electronic information that then feeds into care plans, and then the patient
does the freshened scale again, if they want to, remotely, four weeks after
And so we’re going to have all of that coming in. We have monitor input.
Patient stands on a scale. Patient takes their blood pressure. All of those
results coming in.
Pharmacy inputs. “This patient didn’t get their prescription
filled.” “This patient got their prescription filled the first time,
but they haven’t been back for any renewals.”
Case-manager input. What is going to happen to all this stuff?
Well, you could easily imagine it’s just going to be another great, big
pile on physicians’ desks.
And so what we are doing — We think the only feasible, affordable and
reliable way to do it is to have a central activity where all of these things
And the reason I call it an activity is because it will be partly
automated. It will be fundamentally managed by business process software that
we’ll know if the mammogram is normal and the patient is Dr. So-and-So’s
patient and the patient uses the patient health record or doesn’t and wants
U.S. mail, send the normal mammogram letter from Dr. Walker to this patient via
And so we expect for a lot of this to be managed by business process
management software, which is in heavy use in other industries, almost not used
at all in the healthcare sector.
There’s a call center. If the patient doesn’t show up for a mammogram after
the set time, say a month, where does that signal go? Are we going to send that
to a nurse and put it on her list of 4,000 things she won’t get to today
We’re going to send it to a call center, who will have a script and say,
“Dr. Walker noticed you hadn’t gotten that mammogram done. He wanted me to
call and see if there was anything I could do to help you schedule it.”
If the patient says, “Well, I don’t think I really need it,” then
the script says, “Well, could I schedule you to talk to a nurse educator
and let that person talk with you about why it may be a good idea for
So that the idea is that for all of these processes, for all of the events
that can happen in any one of these processes, we know what the trigger is,
what the message that whoever it is the actor is going to need to communicate
with the patient, so that what the patient gets is the impression that they’re
as well treated as the governor and what we get is fundamentally decreased cost
of care provided per unit of care.
Discharge is one of the things that we’re in the first couple of months of
where we make sure that there’s PCP communication, home health referral, early
monitoring of patients so patients get contacted electronically or by phone
within 24 hours to make sure they haven’t had anything untoward happen to them
in that early timeframe.
We have a commitment to ourselves, no patient is going to leave our
hospital without a follow-up visit scheduled and documented electronically, and
then, of course, have a report that goes to the right people to make sure
So data that prompts a response. I already told you no result can go a lot
of different places because the patient just hasn’t gotten it done yet. An
on-target result, this produces something standard.
An off-target result goes someplace completely different. In this case, the
breast clinic that has a service-level agreement that they’ll contact the
patient within 24 hours of the time that that result is resulted.
This is a little off target for you, but I think it’s worth you having in
the back of your heads. We talk about automation. We’re already doing
automation. We’re going to do a whole lot more of it.
We have very little idea what the impact of all of it’s going to be. We’re
trying to test that. We have six or eight funded research projects around these
kinds of topics going right now, but there are levels of automation, and they
bring different — they have different implications about reliability and about
All big accidents, Bhopal, Three-Mile Island, Chernobyl — one of the
things that characterizes big accidents is highly-automated systems.
That first one where the software activates a protocol without notifying a
human or maybe notifies a human after they’ve done it.
So we are trying to be smart about how much automation is appropriate for
what things, when a human being needs to stay intermediated in a process.
And what we’re doing is disintermediating humans from lots and lots of
processes, which we absolutely have to do or we’ll never get anywhere, but
we’ve gotta be smart about it that we don’t just disintermediate them from
processes that they actually, in the case of nurses, classically, are the glue
that’s holding the whole thing together.
And so part of what we’re trying to do as we do this disintermediation is
test the effects, both in terms of patient understanding and satisfaction as
well as in terms of process reliability and outcomes.
Transparent reporting. You know, we produce reports to all kinds of people,
different kinds of topics, different kinds of information needs. This gets
bigger all the time. I’m not going to talk about it too much more.
I just want to reflect one thing on the implications of all this. It’s been
said the point here is not HIT. It isn’t. The point here is care that is better
than all but the very richest people ever got anytime, the sense that my
doctor, my nurse and my case manager and whoever else is relevant knows me,
knows what I need, knows how I want it served up and knows when I’m ready to
deal with it.
And the only way to achieve that is through a combined system of process
reengineering, incredibly strenuous testing. We do thousands of person hours of
testing a year just on the EHR and an EHR that is robust enough to support all
I’m convinced that what will become the product that physicians will want
to buy is not an EHR, but a system in which they and their nurse and their
front-desk people will be trained in a set of processes and given a set of
tools that will guarantee that, if they’re used properly, produce 100 percent
performance on thousands of process and outcome measures.
And the issue, then, is how do we get to that, and that’s a whole different
question than the issue of how do we get everybody to use an EHR.
DR. STEINWACHS: Jim, thank you very much.
Questions, comments — David.
DR. HUNT: You alluded to it in the last couple of sentences. Wanted to ask
do the inpatient triggers an admission-needs evaluation actually improve your
process measure, quality scores and/or your patient-satisfaction scores?
DR. WALKER: The evidence we have is indirect. There’s so many things
changing that it’s hard to tell, but our — over the 10 years that we’ve been
doing outpatient EHR, our community-practice service line Press Ganey
percentile has gone from 14 percent to 62 percent.
Inpatient, our Press Ganey are very good. They’ve been good. So it’s harder
to — and we’ve only been live about a year on that.
So, yes, we’re measuring that. We believe so. I mean, with the proven-care
CABG, the very early data is 20 percent decreased readmissions, 40 percent
decreased complications on very early data.
I showed some data earlier on diabetes complication prevention,
coronary-artery-disease complication prevention where some of the measures
we’ve achieved 15-20 percent improvements, and all of them have improved some.
DR. HUNT: Because in the SCIP measures, the Surgical Care Improvement
Project measures, 60 to 80 percent of those you can anticipate when the case is
posted. So, you know, wonderful opportunity.
DR. WALKER: Yes.
MR. LAND: I’m not familiar with the state of the art of EHRs, but I heard
that some EHRs can’t even produce a registry or they have to pay $10,000 for a
registry. Just blows my mind.
Has anybody developed what the — it’s kind of your last slide there.
Either one of you can respond to this. As physicians are looking at all these
different vendor-based systems and trying to decide if they can afford any of
them and what they do?
Is there any guidance provided by some organizations to what type of
functionality they should be looking for when they make these decisions, so
that they’re guided by something, as opposed to just the best salesman that
comes through the front door?
DR. HUNT: Actually, there are a couple of tools. There’s — you can get to
it, and I can provide the link, Docket University(ph), which was actually a set
of tools that CMS and the QIO program stood up to actually begin to answer
One of the things that we’re interested in doing is improving some of the
tools within Docket, through ONC, one of which is a wonderful pre-assessment
survey that is actually on HRSA’s website. If you go HRSA HIT, you’ll see the
pre-assessment survey. Has a wonderful checklist of what you should be looking
for, even down to the level of what are some of the negotiating points for when
you try to go and negotiate a contract, what are some of the cultural things
that you need to do in your office before you even bring this in.
Because if you bring this great, wonderful, shiny, new box and software in
and you haven’t really prepped your staff, you’re in for a disaster.
So there are a couple of tools through Docket U, and through the HRSA
website. I’ll be more than happy to provide the links.
DR. CARR: Thanks again for all the great presentations this afternoon.
Just a follow-up question on this. So as we’re thinking about implementing
an electronic health record, what an office might just bring in and plug in and
what you have created with your process redesign are very different, and do you
have a sense of what’s the cost of the process redesign — both the redesign
and the ongoing upkeep?
DR. WALKER: Our direct costs are about $10 million a year.
As it turns out, the software is only 20 percent of our direct costs, so
that bargain software is a really bad bargain, because there is a difference.
In terms of total costs, we don’t have a good estimate. I mean, this is a
case where we really have — what it means to be a successful executive at
Geisinger has changed fundamentally in the last 10 years.
If you can’t do a needs assessment, at least get someone to do one, if you
can’t support a project — not run it yourself, but help support it — You
can’t be a physician leader in our organization if you don’t understand process
redesign at an executive level.
All of our operations leaders have received extensive training. Physicians
and nurses have been trained in everything from simple EHR use to how to make
EHR an asset in the exam room. We codeveloped a course at Bear Institute on
So when you think about the training and organizational change costs of
this, this really does mean saying, “We’re going to transform the way we
do healthcare.” It’s like saying, “We’re going to go from being Ford
to being Toyota” or something.
And so the costs are — But I think the cost-benefit discussion has been at
too low a level.
The EHR is too expensive to be a project for storing records better. It’s a
bargain if what you want to do is transform your business. It’s a bargain and
it’s also essential, but that’s a very different — and that’s not usually the
way we couch that discussion. It’s not usually, “I want an EHR, because
I’m going to transform the way we do everything we do.”
And, by the way, that practice — I’ll personally guarantee the practice
that got all of those criteria done the first year and all of the practices
that you hear somebody presenting in a conference and saying a small practice
can do this, they did that.
They had a leader who was a skilled physician who had the respect of his
partners, but also had a vision for transforming the way they did everything
and put in 40 hours a week extra every week for years transforming not just
their computers, but the way they do everything they do.
If that’s the model, how many practices do you think have a sort of
third-order genius like that? Not enough for us to have a healthcare system
DR. FRANCIS: These are two separate but related themes that have to do with
my trying to pay attention to levels of patient choice in all of this.
DR. WALKER: Yes. Absolutely.
DR. FRANCIS: The first is that in your discussion this morning you
emphasized patient choice, so that if somebody gets the reminder call, they can
tell the reminder call to get lost and it doesn’t come again.
DR. WALKER: Absolutely. And we’re working —
DR. FRANCIS: But I didn’t hear that emphasized in the afternoon.
DR. WALKER: It is assumed in everything we do.
One of the things that we have some ability to do and will have more is to
be able to say, “OK. We asked the patient this. So we’re not going to ask
them this again for a year,” or, “We asked the patient this and we
have documented really careful education and clear understanding, and we’ve
agreed we’re never going to ask them again.”
That’s part of that genuinely-personalized care is that if you really — I
mean, if we’ve done — and that’s one of the things, by the way, we’re going to
need standards on. What is a reasonable educational effort? You know, what is a
basis on which we can say, “OK. The patient clearly understands this.
We’re never going to bother them about this again.”
We’ve got to have accounting systems that count that as 100 percent. Until
we do, we’re going to be in the position — We, right now, as a sector, are in
the position of — without wanting to admit it — forcing clinicians and case
managers and other people to strong-arm patients.
And, no, it’s a very powerful tool. If it’s done right, patients can have
more choice than they ever had before.
I mean, we are working on having locus of control instruments where a
patient can answer a set of questions and we know their locus of control and
assign them to different kinds of communications and things based on their
locus of control, based on their literacy, so that, over time, our goal, at
least, is to let the patient tell us how they want it.
“I want to come in and hold your hand and you tell me what to
do,” and we’ll do that for them, or, “I want you to comment on my
care plan and help me execute it,” and we’ll do that, too. And we’ll
remember which one you are, and all of our communications and all of the things
we offer you will reflect that decision that you made.
DR. FRANCIS: The related theme was that I noticed in your discussion a
broadening out, just as we heard this morning of what a medical home is from
merely a physician to including all kinds of services, such as health coaching
and — if the patient wants it.
Now, I want to link that back to actually what Michael and David — When
David used Michael’s slide, I don’t know whether this was intentional or not,
but in the capture of the woman with diabetes, there was no mention of any kind
of education of her with respect to, for example, weight management.
DR. KLINKMAN: Oh, yes, that was in one of the slides. You just missed it.
DR. FRANCIS: I didn’t actually see it brought out, but I saw — Yes. Okay.
So you are working with the broader notion?
DR. KLINKMAN: Oh, yes.
DR. GREEN: I want to take you back to your very first — well, actually,
your second slide, and I want to ask you to relieve me of a piece of ignorance
Is the word “end to end,” or that phrase, is that a technical
term that has a well-defined meaning? And, if so, what is it?
DR. WALKER: It’s used in other sectors. What it means is that a company
understand its processes all the way from procurement through needs definition,
through product design, through marketing — understanding customers, through
purchasing, through order fulfillment, through customer-relations management,
all the way through to the patient saying, “I love you. I want to buy more
So it’s that idea that all the way — we don’t say, “This is what we
do, and if you need something else, well, that’s tough. Go find it.”
Whatever the patient needs, we know how to do it and we have a process
designed to do it.
DR. GREENS: Thanks.
So as a production, what it takes from procurement to have the customer
coming back, having produced the product and delivered it.
What’s the fundamental procurement step —
DR. WALKER: Well, I wouldn’t say the procurement — In other industries,
you know, if you’re buying things — You know, Wal-Mart, procurement is a huge
For healthcare — in my view, at least — that’s more sort of materials
management. That’s not the core of what we do. The core of what we do is
something different, and I wouldn’t know how to say which step in the process
would match up against procurement. I think care processes are fundamentally
different processes, would be my guess.
DR. GREEN: Thanks.
DR. STEINWACHS: I want to thank all the speakers. This has been fantastic.
I think all of us feel better educated.
MS. GREENBERG: And we’re all moving to Pennsylvania.
DR. STEINWACHS: We’re moving to Pennsylvania. That’s right.
Well, we were moving earlier to North Carolina, but, now, I see we’re
moving to Pennsylvania. So, you know. This is a fickle group. This is a fickle
MR. REYNOLDS: That’s right. You just upscaled our state again. Thank you.
You can vacation there, though.
DR. STEINWACHS: Thank you, sir. Thank you.
DR. STEINWACHS: We did want to move to the opportunity for public who are
here to give us testimony — I believe we have someone from the American
Academy of Pediatrics.
MR. HALL: Right.
DR. STEINWACHS: Would you come up to a microphone and introduce yourself
and then please share with us?
MR. HALL: Thank you so much.
That’s right. My name is Bob Hall. I’m an Assistant Director in the
Department of Federal Affairs here for the American Academy of Pediatrics. I am
not a pediatrician. I am a recovering lawyer. Never quite recover. No, you
But I did want to go ahead and talk a little bit about today, the testimony
that was heard today, as well as yesterday. We had another representative from
AAP, Mark Delmonte(ph), here yesterday as well.
And, you know, it’s always an interesting thing to — You know, we’ve been
doing this for 40 years, and so it’s interesting to sort of have people come to
this idea, at this point now, and see it implemented in the non-pediatric
And just as a step back, you know, we’re dedicated to the attainment of
optimal physical, mental and social health and wellbeing for children. That
also includes very young infants, all the way up to young adults.
And, most recently, the academy has reaffirmed that that means folks up to
age of 25. In fact, in the medical-home context, you know, there are
pediatricians who are actually caring for children who aren’t even children
anymore, who are approaching 30, because, essentially, much of the technology
that’s gotten out there at this point, the handoff is very difficult.
It’s very difficult to find somebody who’s able to really adequately manage
the chronic-care conditions that some of these very sick children have been
able to survive into their 30s with.
So we have a lot of experience with caring for these children, and then,
additionally, the sort of chronic care and community-based needs that these
And, you know, there’s real problems, I think, in terms of what kids are
getting in the United States. You know, there’s probably been testimony — I
wasn’t here yesterday — about the level of overuse, under-use, et cetera, for
adults. That’s about 55 percent of adults get the right level of care, and then
it’s much worse in the pediatric population. It’s actually below 45 percent.
I don’t think that’s necessarily because my doctors are bad. I think it’s
because, generally, the system is very poorly funded that we provide for
And when I looked at what this subcommittee’s charge is as well as the
quality group, you know, there are two things that are very specific that are
important in this context.
One is the vulnerable populations under HIPAA, which is the seventh part of
your work plan, and then, essentially, also under the quality group, you know,
you’re supposed to review existing health and health-related data systems and
their ability to generate meaningful information about quality of care across
public and private sectors.
The public sector for children is not Medicare, and that’s a very important
thing to step away and take in. That is a fragmented state-by-state — You
know, the joke in the Medicaid world is, “You’ve seen one Medicaid
program, you’ve seen one Medicaid program.” Every single one is different,
and the North Carolina model is an excellent, excellent model, but that’s
probably not going to work in Wyoming.
And so recognizing the data and interoperability issues that are brought
forward by that — and then also attending to the seventh point of your work
plan, you know, adolescents have very unique privacy issues that other
populations simply do not have.
So if there’s a kid who goes in for a pregnancy test at the age of 15, when
does that parent get to know about that? And what happens if that person goes
across state lines?
You know, HIPAA just punts on that issue. There are very significant
concerns that I think we need to deal with as we move forward with health IT,
and interoperability generally.
Let’s see. Additionally, you know, in the context of pediatrics, there’s
been so much testimony given by members of the committee who are family
physicians and internists.
Pediatricians are not having problems filling their slots. You know, we do
not have a problem, at this point, at the general pediatrics level of finding
enough pediatricians to care for kids.
At the subspecialty level, we absolutely do, and I think there are very
significant concerns about access to care for the subspecialist slots,
specifically under the public-pay programs, but, generally, if we’re
approaching the medical home as a way to improvement payment, so that we get
more primary-care doctors out there, that’s not really the problem in
pediatrics right now. The problem really is in that subspecialty population.
So if this is going to become — and I’ll talk out of turn here. Maybe I
already am. But if this is going to become a fight between specialists and
primary-care docs, and it just becomes this fight over payment, that will not
help children, because there are going to be a lot of those kids who are going
to need to see a pediatric endocrinologist. There are a lot of those kids who
are going to need to see a pediatric pulmonologist, et cetera, and it’s hard to
find those people, certainly within the public-pay system.
So I would really caution this committee from making some recommendation
that payment automatically must flow in this direction, because I’m not sure
that’s ever what we considered the medical home to be. And I’m not sure it
necessarily works to the betterment of children, even though, as the payment
lobbyist, I will note that my docs get paid 70 percent of Medicare under
Medicaid, on average. That’s not a good situation.
Nevertheless, I do think that we have other issues that we have to deal
with in terms of the quality measurement in pediatrics. We simply don’t have
the quality measures that are there on the adult side, and so part of the
lobbying we’ve done in the past is really to try to get some of those quality
measures through the pipeline, through the NQF process, et cetera, to really
get kids better opportunities to receive better care.
Let’s see. Two things that are not within the joint principles of the
patient-centered medical home that I think are very important in the pediatric
context, and that we’re still very committed to, are the family decision-making
component of it. I mean, certainly, it’s the patient-centered medical-home
model, and that makes a lot of sense in the adult side, and some childhood
instances it makes sense, too.
But most decisions that are made for the pediatric population are made by
the family, not by the child, and there are important things that flow from
And then, additionally, one of the things that’s incredibly important and I
think I only heard mentioned maybe once or twice today is the
culturally-competent component of what the AAP thinks is important in a medical
This is essentially — you know, there was — one of those questions was,
“Were you offered an interpreter?” in the pediatric context of the
medical home, and, you know, that’s a really important question, but it’s not
just interpretation. It’s not language interpretation. It’s also the reality
of, you know, people of Hispanic descent or Latinos may look at the healthcare
system in a very different way than people who are of Anglo descent may.
And so that’s something that we would really hope does not get lost as we
move forward with more of this patient-centered medical-home activity.
So we think that the medical home is a great way to attack disparities.
Disparities are rampant within the pediatric population, and in terms of, I
would argue, the adult population as well, and this is a real opportunity to
deal with some of those things.
But I think we kind of have to keep the patient centeredness of this
medical home out there. And there is a real need, we think, for the
continuation of the focus on cultural competency, the continuation of the focus
on the community aspects of care, specifically that children receive, as well
as probably adults.
But pediatricians really are on the phone a lot, you know, trying to
coordinate care for kids going to and from schools, through hospitals, through
— you know, making sure that churches, et cetera, are providing services,
because it really is not just about the physical wellbeing, but also about
social and mental and other wellbeing that we interact with all the time.
Additionally, as you go forward with recommendations on health information
technology, there are some very specific things in the pediatric population
that we’d really like to make sure that folks take a look at.
For instance, health IT systems that do not include milligram per kilogram
weight based dosing have real possibilities to be detrimental to the pediatric
Additionally, those that don’t have growth charts on them don’t make much
sense for kids below the age of two.
And then, finally, it would be nice to have head circumference available on
some of these, because that matters for pediatric populations and very young
Additionally, I’ll just note again that adolescent privacy concern that’s
there, that is incredibly important for that population.
That’s about it.
But I want to thank you, as a taxpayer, for all the money and time you guys
have spent just coming here and doing this. It helps my government work better.
And I know you don’t get paid really anything — right? — to do this. So —
MS. GREENBERG: Well, a little bit.
DR. STEINWACHS: It may be value-based purchasing, in our case. (Laughter).
Thank you very much for contributing to this hearing. Appreciate it very
Is there anyone else?
DR. STEINWACHS: The next stage we’re going into, Justine volunteered.
Actually, she was absent from the meeting in which we made the decision on
the final agenda, and we knew that she was the one to lead us through the
discussion of what are the key things that we’ve heard that ought to shape sort
of our thinking about next steps and begin the discussion about the kinds of
recommendations, and, certainly, we aren’t going to settle all that, but now’s
a great time to sort of summarize and pull together.
DR. CARR: Right. So thanks, and I have two slides. I just wanted to sort of
do a big-picture context on this of some conversations we’ve been having
throughout the two days.
And then the second slide is just what were the goals of this — No, we
talked about what the goals are, but what is the charge of NCVHS.
Somebody just stole my thunder a little bit about what we say we’re going
to do, but I think it helps ground us, because we’ve heard just some phenomenal
presentations today, very exciting things, but we want to stay grounded in what
NCVHS has been charged to do.
So going back to the picture of the primary-care doctor caring for someone
in his office, it made me think this way: We think about what care used to be
like, maybe not even all that long ago for some of us, the old and then the
So when we think about available information, it used to be, for some of
us, that it was all in the textbooks, Harrison’s Principles of Medicine, and it
would be updated every four years, and we would look forward to that, but
what’s happened today is that information is not finite anymore. It’s infinite
on the internet, and the need that we’re facing with that is to synthesize the
relevance for the patient.
A second thing is, as I said — well, old information, at least we thought
it was relatively static. It didn’t change as quickly, but, now, it’s very
dynamic. Up to Date, which is one of our resources on our intranet, updates, I
think, every six months. So this has implications then for clinical decision
support, both for providers and for payers.
Information that we have may have more relevance as new information comes
up, and so our need — this need column is how we think about some of the
things we’ve articulated in the patient-centered medical home.
A third thing is just mastery of information. There was a time when a
generalist was really — could do it all, and now we know it’s generalists and
specialists, and so one of our needs in the medical home is referral network.
Performance improvement. I think, at least when I trained, a lot of it was
about what was your last experience, your last patient. What went wrong,
because you’re not going to do that again and you’re going to learn from that
And, now, we know much more about population-based outcomes, and the need
that we now recognize is the need for registries. And, also, as we heard about
in the North Carolina example, is not just the registries and the information,
but the medical management teams that evaluates that data and develops
The care-team center used to be the physician. Now, it’s the patient, and
it has important implications for patient health record, access and ownership
of their data, care plans and decision making.
And then when you think about the setting of the provider, a physician used
to see you in your home, would also see you in your office and would also be
the person seeing you in the hospital.
And, today, it’s the VNA who may be seeing you in your home may be a
midlevel practitioner, or the PCP seeing you in the office, and it’s a
hospitalist or an intensivist seeing you in the hospital.
And this is where we come to the need for the team approach with
communication. I think what was driving me to put all this together is what
So two things happen. The world changed, and we’re trying to recapture what
we used to have, but we have to do it, I think, in a different way.
And so then just continuing on in terms of the importance of longitudinal,
when we lived in stable communities and had a single provider who took care of
our parents and our grandparents, there was longitudinal, and it didn’t need
any other construct, but, today, we live in a world of transient communities
and people have multiple providers, and, therefore, we see the need of
interoperability of information in usable terminology.
I’m almost done.
Moving on, community support. It used to be that if you were sick, your
family, your neighbors, your clergy would be there to support you.
In this environment today, where everyone is working and everybody else is
living out of town, we have this new need of case management and community
Finally, payment, when you got your percent of charges, and, now, today,
we’ve moved into all these different permutations, not there yet, but from
capitation to pay-for-performance.
And, finally, another word, I guess, about payment. It’s not quite finance,
but the visit is what you got paid for, but we now have a need to pay — we’re
delivering care in the visit, but all the care coordination outside of the
visit, and, therefore, the need for the per-member-per-month.
So this was just my way of saying how did we come to this need? We know
what we’re trying to achieve, but to understand that we’re just — we’re
redesigning how we deliver care and how we get care in this new environment.
So my next slide then was to just — Let’s see. Oh, no. This way. I’m not
very technologic, even though I’m from Beth Israel Deaconess.
So this was from our meeting in February, where we tried to talk about how
we were going to focus on the work we’re doing going forward, but our areas of
focus for NCVHS have to do with data needs, assessment and emerging data
issues, and that’s a lot of what we’ve been doing here today.
Focus on data-collection strategies. The importance of multipurpose,
integrated, shared multiple uses of the data collected once. Again, very much
of what we’ve heard about today.
Data standards, terminology, classifications, ICP, ICD-10, SNOWMED.
Information network design. Interoperability. Privacy and security.
And actually had HIPAA on here, and I should have left it on here for the
reasons we just heard about all these issues of adolescent privacy and so on.
So I’ll stop with that and open it up for discussion, because I think what
will be most important is for us to have a focus that’s not too granular and
not too macro, but can add value to this wonderful set of hearings.
DR. STEINWACHS: I’ll fill part of your void.
You know, I guess what was striking to me, and it probably shows my biases
of background, was the sort of discussion that talked about the overlap and the
lack of complete overlap between primary care, medical home and chronic-disease
management, and, indeed, talking about different underlying models that say
what do we know is the attributes of good primary care, what do we know
currently about good chronic-disease care and where does the medical home sort
of fit that overlaps but not completely?
And so it sort of left me with a feeling that, in the best of all worlds —
and maybe the medical home is the least well- — consistently defined, but at
least the vision, I think, is out there — is it would be good to be measuring
all three is to have a way to measure the extent to which primary care, as we
understand it in other countries and as part of your old system there, in a
sense, you know, is being provided to people, the extent to which good
chronic-disease management is being provided to those who need it. And,
certainly, the Medicare medical-home demonstration sounds like it’s going to
focus very heavily on the overlap between the medical home and chronic-disease
management, because that’s the way the populations are going to be selected.
And so I would like to at least have us think about that because I think to
leave any one of those behind — to sort of cut out primary care or to cut out
chronic-disease management and just to elevate one of those at this point seems
to me leaves the country as it sort of looks at how do you deliver the breadth
of care you need, because chronic-disease management has a lot more specialty
The medical home is the interface between specialty and primary care and
primary care is the entry point to our healthcare system.
Leslie, why don’t you — We have Justine running this part of the meeting.
DR. CARR: Oh, sorry. I wasn’t sure —
DR. STEINWACHS: (Laughter). This is my — you know — I’m getting tired. So
DR. CARR: Leslie.
DR. FRANCIS: One of the themes that I heard yesterday at the beginning that
I suspect was implicit, but not explicit, as things went along, was health
disparities and whether there are any data to look at the question of whether
better access to a medical home reduces or in any way effects health
And that — with chronic care and people with disabilities, that would be
one disparity issue, but the disparity issues of, for example, race and
ethnicity and sex haven’t been mentioned at all.
MS. GREENBERG: We had a little bit of discussion about that on our
conference calls when we were planning this, and we had actually hoped to have
a presentation from the Office of Minority Health, but then it didn’t work out,
but maybe our representative would like to say something.
MS. GRANTHON: This is Miryam Granthon. I’m the staff person to the
Populations Subcommittee from the Office of Minority Health.
Actually, the Commonwealth Foundation hosted, last summer, in June, a
report on how having a medical home does assist in the elimination of health
disparities, and Dr. Garth Graham, the Director for our office, was one of the
I’d be happy to provide that to Matt electronically so everyone can get it.
Dr. Graham did wish to be here this afternoon, but he was traveling
yesterday, and just last week, his plans were changed. So —
But we did have the discussion, and I think, as you’ve mentioned just a few
seconds ago, it was discussed within some of the presentations, but not as a
But I’ll be forwarding that document.
DR. FRANCIS: If there are data that are needed to help assess that better,
that might be a role for this committee to think about.
MS. GRANTHON: Thank you.
DR. BREEN: In terms of data, cancer is a really good example of data gaps
for trying to show that we — As opposed to end-to-end care, we usually talk
about the cancer continuum, which starts with a healthy population and ends
with death from cancer or some other cause.
And the first sort of step into the healthcare system would be through
screening with the possibility of diagnosis.
But one of the things that we lack, in terms of data, is a continuity of
seeing individuals go through the system. For example, with — if you wanted to
look at cancer screening, the National Health Interview Survey is the data
source that you would use. So we have very good national estimates by race and
socioeconomic status on who’s getting — and age, of course, and gender — on
who’s getting screened.
And then the next step is a cancer registry, which NCI started the SEER
data registry, and, of course, CDC has come up with a registry which is now
And so we know who gets cancer. We know their stage of diagnosis. We know
who dies from cancer. We know what their treatment is.
There’s a few gaps in terms of treatment information, but we don’t know, of
the people who get screened, who ends up with cancer, by and large.
So there’s a gap there in terms of the data, and that’s a giant gap,
because getting screened or not getting screened is really going to determine
whether you get early-stage cancer diagnosis, and that’s what’s going to
determine what your prognosis is.
So there are NCI has also started a project called the Breast Cancer
Surveillance Consortium, which collects data in some selected places and is
basically a mammography registry, but it doesn’t have the extent of
socioeconomic and background data, including insurance and access to care that
the National Health Interview Survey does.
So we’ve got a lot of pieces, but we don’t have a nice, continuous,
thoroughgoing set of data like we would need.
And then the other piece is the SEER data has no socioeconomic data
associated with it. What some people have called the holy trinity of age and
gender and race are collected, and, for a long time, that was distressing,
because it was looking like race was driving an awful lot of stuff that we
figured was probably due to socioeconomic status.
So those data have been linked to the SEER Medicare data for the population
65 and older, but we still — we have a gap now for the under-65 cancer
diagnoses. We don’t have that additional information for them.
So you can see where we’ve tried to sort of piece together things, but
there are some pretty major gaps in our datasets, and so cancer is one possible
example of how — where the gaps are, where we’ve tried to fill in some gaps
and where some gaps remain.
And so your question can’t really be answered for cancer, for example.
But you can see, from the screening data, that people who don’t have a
usual source of care are the rock-bottom least likely to get screened for
cancer, and that tends to be driven by insurance coverage.
But in terms of rates of screening, they are lowest for people without a
usual source of care.
DR. STEINWACHS: When we were talking about planning these hearings, Larry
kept saying to me, I thought, that we ought to be thinking about the data model
that underpins the medical home. I guess you could broaden that and talk about
the data model that may underpin primary care as well as chronic-disease
And I thought we had some excellent presentations really trying to talk to
that data model, and Mike’s here.
And so I don’t know whether that’s an area in which there’s a contribution
that we can make to try and elevate that, because, then, it seems to me, it
links maybe Justine to some of the HIT issues of how do you support that data
And not all of it necessarily has to be high tech, but it seemed — in some
presentations, at least — that reminded us that data model may be pretty
And, Mike, you’re nodding your head. Maybe —
DR. KLINKMAN: I think — We’ve been trying to build some of the data-model
stuff piece by piece on kind of a one-off basis, and it takes work, but I think
that it is feasible to build pieces and then allow them to connect.
And I think that taking on another piece and seeing whether it works and
taking on another piece and seeing how it fits together is one way to try to
get at the data model, if you kind of know where you’re headed.
The trouble, I think, with some of what I’ve seen in HIT, as I’ve
experienced it as a clinician, is we don’t know where we’re headed. You know,
we just did the last thing again with the health record, and I think we need to
think about where we want to go.
DR. STEINWACHS: I guess what I took away was that — I think what you’re
saying is that it would be great to have a vision that says, “Here is the
fundamental data model.”
It may not have to be that detailed, but talks about where it’s going and
then recognizing that you’re going to fit in maybe pieces at a time and some
may be automated, some may not, but at least you have a vision of where you’re
MS. GREENBERG: I thought the partnership that developed between Michael and
David was very good.
DR. STEINWACHS: Yes.
DR. KLINKMAN: We just changed cards.
MS. GREENBERG: Well, no, but when you took his –
DR. KLINKMAN: — homes next week and —
MS. GREENBERG: Well, you took his slide and then showed where some of the
standards work has gone, but I think it demonstrated the way we’re approaching
the standards work.
And, you know, it’s very hard to do a holistic look at standards. I mean —
and I understand where the use-case approach came from, and I think it’s been a
learning experience, as you said, and we’re now going into sort of phase two or
phase three, but I think we’re at the point where it’s kind of like which part
of the elephant are you touching, and where we need to work — I think the
committee needs to work with ONC and the AHIC’s successor, as we have been
trying to — as we’ve been doing over the last few years, and how do we go from
that kind of approach to more of a holistic approach, based on a model of care
that — the data model that supports a model of care, such as we’ve heard
I mean, I can’t imagine there’s anyone, as a patient, or as a consumer, who
would hear about some of the aspects that have been talked about here who
wouldn’t say, “Oh, that would be so nice.”
Now, it may be you have issues about, “Well, I’m not so sure I want to
share that information,” or, “I’m not so sure that I want to have to
go to a primary-care doctor, if I already have a good dermatologist and want
something — you know — and I have confidence in him.”
So, I mean, it always breaks — the devil is always in the details, but the
idea of actually having your care coordinated, you know, and all of this, I
mean, it sounds like Nirvana to most of us, probably, who’ve never had that,
since we were probably a child, when we didn’t have many health conditions.
DR. BREEN: And our moms did it.
MS. GREENBERG: Our moms did it, yes. That’s true. But also we didn’t have
that many health — I mean, the fact is, as you age, maybe it’s not inevitable,
but it does seem that — you know — that does go kind of with the territory,
more health conditions.
So I’m just wondering if there isn’t some way that we can’t start using
these discussions —
And I absolutely agree with you that I think we can’t just get focused on
this medical home. I think it’s gotta be some synthesis of the primary care,
the medical home and the chronic-disease management, and, of course, throw in
reducing disparities and a few other things as well, but into the — what kind
of — I said earlier this morning, it’s not our role to redesign the health
system. That’s true. But it’s our role to try to recommend information gaps and
needs, et cetera.
But what we want to recommend — make those recommendations are in
relationship to, obviously, a more effective and efficient healthcare system. I
mean, we have a goal at the end, which is better health and more of a
population focus, which, of course, this is a population subcommittee.
But this is about the only — one of the few times that I’ve been in a
discussion about clinical care where population kept coming up. I mean, even if
it’s only the practices population, it’s still a step in the right direction.
So I think we — I really hope we can continue to work with you, David, and
with ONC and AHIC’s successor, et cetera.
I’m trying to move this whole standards development more towards this
holistic — that’s the only word I can think of. There might be a better one —
approach, but I do think, right now, we have different pieces of the elephant,
and we kind of have to take your word for it that, “Well, this will do
this and this will do that,” but there’s not a great deal of confidence,
and from what we’ve heard about all these systems out there that are not
interoperable, that it’ll all come together.
DR. HUNT: And I think the same revelation was really expressed at the last
AHIC meeting, and, to be quite honest, they held the Secretary’s feet to the
fire, and, by extension, ours, that —
MS. GREENBERG: I bet.
DR. HUNT: They said that they really need to see — OK. We’ve done a lot of
things. They’ve gotten a lot of use cases, we’ve had a lot of standards, but
how much of the elephant are we seeing? Where are we?
And I think that, again, the June 3rd meeting will — it won’t
give us the whole big picture, but Rob has probably job one of his piece of it
to begin to articulate how we’re going to go along that path and figure out
what we have, because that was a very, very — it was said again and again and
again that, you know, “Where are we? We know we have this. We know we have
this, but where does this all fit in? How much can we completely do in terms of
taking care of a patient? I know you have labs and I know you have meds. Do
they fit together?”
And rather than extend and talk about other things, I think that was very,
very loud and clear from the majority at the AHIC.
MS. GREENBERG: Can I just say one more thing? This’ll be short.
DR. STEINWACHS: Marjorie, of course.
MS. GREENBERG: Thank you.
DR. STEINWACHS: You can always —
MS. GREENBERG: Well, no, but — This will be short.
But I really do think that if anyone is serious about this patient-centered
care, which — you know, it’s part of the medical-home thing, patient-centered
— we absolutely have to come up with a way to collect exactly what Michael
said, which is the patient’s reason for seeking care and counter visit,
whatever you want, and this idea of their goals, and — I mean, preferences
relate to the cultural competency, that’s for sure, but, to me, it’s — I hate
to use this word, but it’s almost a joke to talk about patient-centered care in
which there is no systematic collection or way to capture and to classify what
the patient —
You know, you’re not going to see anybody. I mean, if a patient doesn’t
have a reason to show up, they won’t. You know, this isn’t — we’re not in a
prison here. People are on their own as to whether they show up or not, and
we’re clueless as to why.
DR. KLINKMAN: And for the primary-care enterprise, in particular, much less
so than for the disease-management enterprise, but in the primary-care
enterprise or the primary-care medical home, getting from a reason why you come
in or a problem to a disease is not —
MS. GREENBERG: Linear.
DR. KLINKMAN: — a simple process, and we want to know where the twists and
turns there are. We need to know that.
DR. HUNT: And it has to be the primary-care group. This is wholly in their
bucket. I’m a surgeon. When people sit in front of me, they have a problem. So
DR. STEINWACHS: Once you cut it out, they don’t have a problem anymore,
DR. HUNT: I give them a new problem — (laughter).
MS. GREENBERG: You know, I was just sitting here —
PARTICIPANT: This all being taped —
MS. GREENBERG: Through the whole day, I was sitting here thinking, it’s so
much easier for surgeons.
DR. HUNT: Oh, gosh, it is. And that, to be quite frank, is part of the
attraction toward the specialties, that it is a very, very narrow focus, and,
in my practice, I have the ability to say, “I can’t help you because you
don’t fit in within these bounds of what I do.”
DR. STEINWACHS: I’m going to let Harry clarify all this, and then I have
another little word on the side.
MR. REYNOLDS: Well, I’m not going to clarify, but tomorrow I’m going to be
asking this committee to do some things. So I figured I’d put some of them on
the table today.
MS. GREENBERG: It’s a new day.
MR. REYNOLDS: Yes, that’s right. As we look at — the interesting thing,
and I’ve pretty much been a piece of about every committee except Quality, you
know, the workgroup, but as you listen today, this group has tended to be about
population health and population statistics and other things, and this was an
interesting vision today. I mean, the last day-and-a-half has been a really
good vision about what we ought to be thinking about, not — you know, exactly
how to do it isn’t clear yet.
And as I think of the other committees that we have and the things that we
need to deliver — and, again, having implemented HIPAA, somebody said that
we’re not — Marjorie, you made the statement that we’re not about changing the
health system, but when some of us implement HIPAA, it feels like it.
MS. GREENBERG: Yes.
MR. REYNOLDS: It feels like we’re changing it one field and one system and
$1 million at a time.
And so as you guys — as this committee continues to look at the vision
that was put out today, whatever you call it — And I like the idea of the data
model only from a standpoint that it’s not a dataset. It’s the data model,
where you’re trying to go, because the minute that you start putting down some
ideas of where we ought to go based on everything we’ve heard in the last
day-and-a-half, then I promise you, having just finished cochairing Standards
— and I looked at one of the charts, and I’ll use it again tomorrow, where if
you go back to what we’ve already listed in Standards that we ought to be
thinking about it, ICPC was on there, even though I didn’t know exactly what it
meant. I know a heck of a lot — I know more about what it means now, and the
next Standards hearing may have a little more discussion about why that’s
important, because it was there only because somebody on the committee knew
that it was important. We didn’t get it. I know I didn’t get it and I was
cochairman of the group, but this last couple of days has made you get it.
I’m looking at a lot of the EHRs and PHRs. Right now, for example, we’re
coming up with characteristics of them, and in North Carolina, we’re looking at
helping people buy them and do other things, but do they really have the
characteristics that would help in the coordination of care and better health
or are they actually running a practice or are they actually doing some other
And so you guys are positioned, as this committee, to kind of put a
discussion topic out there — and I’m not saying the medical home. I’m talking
about just what do we need to do to do what we’re trying to do?
And then the rest of the committees could also feed off that. Whereas, in
the past, I felt a little disconnected from some of this because it was,
“Well, whatever was there, we’ll take it, and we’ll kind of work with
Well, I think it would be great to almost move Populations a little closer
to the front, and say, “And this is what we ought to be thinking about.
So, oh, by the way, why don’t you guys step up and take a look at it?”
MS. GREENBERG: Yes, we’ve been trying to do that for years.
MR. REYNOLDS: Well, I know, but I’m — I know, but new day, like you say.
Let’s move it.
MS. GREENBERG: You’re getting religion here.
MR. REYNOLDS: No, no, but I think the point is because then if you talk
about data and quality, what are they going to do, and you talk about the
others, at least let’s paint a different picture of the future, and as we look
at asking each committee to have some subjects that are visionary and some that
are near term and some that are things that we just gotta kinda do now, it adds
a different view.
So I’ll be asking every committee that breaks out in the next — tomorrow
afternoon and the next morning to come back with the things they’re going to
Well, I hope they’re somewhat coordinated, and as I looked through this
list with Justine a little bit ago, some of the stuff that was listed on things
we ought to look at in Standards, now, I understand that it might be a decent
time to take a look at it, and it was there before because somebody on the
committee kind of thought that, not necessarily that we had bought into it.
PARTICIPANT: Very good.
MS. GREENBERG: I love this. I love the idea. We’ve never done this in my 25
years working with the committee, because — but the idea of actually having an
all-committee project that each subcommittee — you know — did its piece on.
I mean, still, we have to recognize there are things we have to do. You’re
still going to have to figure out about the NPI and —
MR. REYNOLDS: We got those.
MS. GREENBERG: — and all that, but sort of all rallying around a major
focus or project, it’s the type of thing Paul would have recommended, but
instead Harry did.
MR. REYNOLDS: He and Justine have taught me well.
DR. STEINWACHS: Well, I just wanted, before we close, to again thank Dr.
Matt Quinn, who if it hadn’t been for Matt — (applause).
Larry was trying to get me to focus on these issues, but I could never
quite get focused enough into a translation, and Matt translated all this into
a great program, and Larry certainly guided that, and I consider myself only
the facilitator of trying to make this happen, but —
DR. BREEN: You did a good job.
DR. STEINWACHS: Oh, thank you.
DR. BREEN: A very good job.
MS. GREENBERG: And this is like full time — you know — life’s work now.
It’s not like you’ve done this hearing and then you can go back — (laughter).
PARTICIPANT: You never go back.
DR. STEINWACHS: Never go back.
But, you know, it also, in a sense — Harry was talking about Populations
and how it might drive something, it brought me back to the minimal datasets
issues of — you know — now —
MS. GREENBERG: Our youth.
DR. STEINWACHS: Our youth, yes.
But, you know, there’s a nice progression to a next level of data models
that we started out with the encounter, with the hospital discharge, with the
pieces of the system in terms of — and, now, we’re trying to talk about what’s
the data model that essentially puts the pieces together that, in a sense,
we’ve done some definition on to support healthcare and the health in the big
letters and not just disease.
So I want to thank everyone for their participation. This was a great joint
Justine, you know, it seems to me the agenda really bridged very nicely,
both the population issues and the quality and data issues.
MS. GREENBERG: And standards kept coming up constantly.
DR. STEINWACHS: Yes. And Matt made sure that we didn’t — you know, that
those of us who are paper-based at heart, you know, recognized that there was a
revolution in health information technology and got that on the agenda, which I
think the sessions that we’re talking about, you know, what are the strengths
and limitations of HIT, and Michael very much contributed to that, you know,
because we aren’t going to find the solution overnight if we’re waiting for the
full implementation HIT. So it is an interactive process.
(Whereupon, the meeting adjourned at 5:32 p.m.)