7
Healthcare Delivery Organizations

Coordinator


Robert M. Crane, Kaiser Permanente Institute for Health Policy


Other Contributors


Madhulika Agarwal, Veterans Health Administration; Denis Cortese, Mayo Clinic; Benjamin Druss, Emory University; Kate Meyers, Kaiser Permanente Institute for Health Policy, Jonathan Perlin, HCA, Inc.; Richard Platt, Harvard Medical School and Harvard Pilgrim Health Care; Laura Tollen, Kaiser Permanente Institute for Health Policy

SECTOR OVERVIEW

This chapter focuses on healthcare delivery organizations and is limited to two major entities: (1) integrated delivery systems (IDSs) and large physician groups and (2) hospitals. The discussion excludes physicians in solo and small group practices because such practices are too small to provide the organizational infrastructure that is the focus of this sector. However, it should be noted that physicians in solo or small group practices (2 to 10 physicians) make up fully 99 percent of office-based physician practices and that 89 percent of the physicians in the United States are in solo or small group practices (Hing and Burt, 2007).

Without major changes in clinical practice by these physicians, no amount of change by the more organized delivery sector will enable achievement of the Roundtable’s goal (smaller clinical practices are addressed in Chapter 5, which describes the healthcare professional sector). Despite the number of nonorganized physicians, however, healthcare delivery organizations play a critical role because of their ability to drive practice trends, set standards, and influence smaller practices by sharing information, resources, and guidelines. A key to achieving the Roundtable’s goal will be to improve the organizational infrastructure for physicians who are currently non-



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 149
7 Healthcare Delivery Organizations Coordinator Robert M. Crane, Kaiser Permanente Institute for Health Policy Other Contributors Madhulika Agarwal, Veterans Health Administration; Denis Cortese, Mayo Clinic; Benjamin Druss, Emory University; Kate Meyers, Kaiser Permanente Institute for Health Policy, Jonathan Perlin, HCA, Inc.; Richard Platt, Harvard Medical School and Harvard Pilgrim Health Care; Laura Tollen, Kaiser Permanente Institute for Health Policy SECTOR OVERVIEW This chapter focuses on healthcare delivery organizations and is lim- ited to two major entities: (1) integrated delivery systems (IDSs) and large physician groups and (2) hospitals. The discussion excludes physicians in solo and small group practices because such practices are too small to pro- vide the organizational infrastructure that is the focus of this sector. How- ever, it should be noted that physicians in solo or small group practices (2 to 10 physicians) make up fully 99 percent of office-based physician practices and that 89 percent of the physicians in the United States are in solo or small group practices (Hing and Burt, 2007). Without major changes in clinical practice by these physicians, no amount of change by the more organized delivery sector will enable achieve- ment of the Roundtable’s goal (smaller clinical practices are addressed in Chapter 5, which describes the healthcare professional sector). Despite the number of nonorganized physicians, however, healthcare delivery organiza- tions play a critical role because of their ability to drive practice trends, set standards, and influence smaller practices by sharing information, resources, and guidelines. A key to achieving the Roundtable’s goal will be to improve the organizational infrastructure for physicians who are currently non- 9

OCR for page 149
0 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE organized and/or in small groups, and healthcare delivery organizations can play an important role in facilitating that improvement. The task in this chapter is to describe how healthcare delivery organiza- tions can enable the generation and use of evidence. “Evidence” itself is a murky concept, and there has been much debate over what type of infor- mation qualifies as evidence for the purpose of “evidence-based medicine.” Most experts agree that the results of randomized controlled trials (RCTs) would qualify as evidence, but there is less agreement about the validity of other types of information, such as observational research and expert opinion and consensus. For the most part, the means of the “generation of evidence” in this chapter excludes expert opinion and refers mainly to more formal types of research and observational analysis (such as the analysis of large datasets created as part of the usual delivery of care), whether or not the findings are published in peer-reviewed journals. Also included is evidence generated by mathematical modeling techniques. When the “use of evidence” or the “dissemination of evidence” is addressed in this chapter, the origins of such information are not specified but are assumed to come from sound research rather than from accepted standards of community practice. For further discussion of the definition of “evidence,” see the charter statement for the Institute of Medicine’s (IOM’s) Roundtable on Evidence-Based Medicine (IOM Roundtable on Evidence-Based Medicine, 2006). To answer the question of how healthcare delivery organizations can enable the generation and use of evidence, semistructured interviews were conducted with sector members and other experts from relevant organiza- tions.1 Over the course of these interviews, two general themes emerged: (1) significant data aggregation is critical, and information technology is fundamental to such aggregation; and (2) healthcare organizations need to have a culture of using everyday healthcare delivery as a learning tool and a means of generating evidence. Data Aggregation and Information Technology Without information technology to enable the aggregation of data across settings and time, the practice of evidence-based medicine becomes nearly impossible. Data aggregation can take place at the level of a single delivery organization by using a comprehensive electronic health record (EHR), or it can take place at the level of an external third party, such as a payer, that can combine claims data from multiple providers. An example of the former is Kaiser Permanente’s implementation of KP HealthConnect, a system that integrates the electronic medical record with appointments, 1 For a list of interviewees see below references.

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS registration, and billing, linking facilities and providing physicians and patients with online access to clinical information 24 hours per day (Kaiser Permanente, 2007a). Another example is the Veterans Health Informa- tion Systems and Technology Architecture (VistA), which integrates patient records and administrative data to provide real-time data access across more than 150 healthcare facilities and 800 clinics throughout the United States and in several U.S. territories. Examples of multiorganization systems include the Cancer Research Network, sponsored by the National Cancer Institute and the HMO Research Network, and the American Medical Group Association’s collaborative database of 1.5 million patient records. All of these systems have in common not just the ability to aggregate data but also the analytic capacity to organize and retrieve data in useful ways. Culture of Continuous Learning The interviewees agreed that there simply are not enough RCTs to keep up with the ever-advancing onslaught of new technologies, procedures, drugs, and so forth in medical care (let alone the already established tech- nologies for which evidence to support their use may or may not be avail- able). Such trials are costly and time intensive, and their results may not be generalizable to patient populations not included in the study, rendering RCTs unrealistic as the only acceptable standard of evidence generation for the majority of medical practices. Some experts have also noted that the peer-review process for publication of RCTs is narrow: typically, only a handful of reviewers, selected by the journal, examine a research study and its findings before it is deemed publishable. It is only after publication, when the study has already, arguably, become “evidence,” that a broad array of experts can examine it and test its findings against their own expe- rience in real-world situations. Furthermore, the amount of evidence avail- able to support each and every medical decision will increase exponentially in the coming years and decades as massive amounts of information become available from the fields of genomics and proteomics. Organizations need to learn to make continuous use of their own observational data and, in the words of Lynn Etheredge (2007), become “rapid-learning health systems” as they face a learning curve that becomes continually steeper. Rapid-learning health systems are those that can combine the clinical experiences of their patients (and, possibly, the experiences of other organizations’ patients) in a searchable database that can be used for research. Such organizations view every patient encounter as adding to the collective knowledge of the group and as a means to test a hypothesis so that others in the group can benefit from the knowledge that is generated. Although this chapter focuses on physician group practices and hospi- tals separately, it is important to emphasize that both types of organizations

OCR for page 149
2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE will provide the greatest value to the field of evidence-based medicine by cooperating with other organizations within the larger delivery system. For example, data obtained from inpatient settings alone can be misleading, as patients receive care in many settings. Research into what works must take into account the fact that critical follow-up care after hospitalization takes place in the community. This follow-up care can have a huge impact on whether or not the care provided in the hospital can be considered effec- tive. As a result, evidence about hospital-based care is not entirely separable from evidence about physician organizations. IDSs that are fully integrated and that combine inpatient and outpatient care delivery are particularly well positioned to track the delivery of care across settings. The following sections of this chapter present an overview of the specific practices that healthcare delivery organizations use to generate and use evi- dence in clinical decision making. The chapter also provides a description of the challenges and a set of opportunities. At the outset, however, it is impor- tant to recognize the distance between the status quo and the goal of the IOM’s Roundtable on Evidence-Based Medicine. Reaching the goal of having 90 percent of clinical decisions being evidence based by 2020 will not be easy. Healthcare delivery organizations know how to generate data; but data are not the same as usable information, and the availability of usable information does not guarantee its use. Furthermore, the generation of evidence is not without cost. Although the current practices, challenges, and recommenda- tions are a useful start, overcoming the gaps in data, information, and the will to change must not be underestimated. Reaching the Roundtable’s goal by 2020 will take more than tinkering around the edges of the healthcare delivery system. Rather, it will take fundamental restructuring and rethink- ing by all stakeholders, as was recommended by the IOM in its 2001 report Crossing the Quality Chasm (Institute of Medicine, 2001). Current Practices As noted above, this chapter addresses two major classes of healthcare delivery organizations: (1) IDSs and large physician groups and (2) hospi- tals. A simple description of each of these subsectors is warranted. Integrated Delivery Systems and Large Physician Group Practices As described by Enthoven and Tollen (2005), IDSs are organizations built on the core of a large, multispecialty medical group practice, often with links to hospitals, laboratories, pharmacies, and other facilities and often with a sizable amount of revenue based on per capita prepayment. Examples of IDSs include delivery organizations that also have an insurance function, such as Kaiser Permanente and Group Health Cooperative. Also included in

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS this category, although it is not technically an insurer, is the Veterans Health Administration (VHA), which delivers extensive healthcare services and also purchases (finances) services that are not available within the organization. This chapter also discusses large public and private physician group practices, which may or may not have links to a specific health plan. Many of the nation’s largest and most well-known private multispecialty physician groups, including the Cleveland Clinic and the Mayo Clinic, are members of the Council of Accountable Physician Practices, which seeks to foster the development and recognition of accountable physician practices as a model for transforming the American healthcare system (Council of Accountable Physician Practices, 2007).2 Other groups that represent IDSs and large physician group practices include the American Medical Group Associa- tion and the Alliance of Community Health Plans (Alliance of Community Health Plans, 2007; American Medical Group Association, 2007). Many publicly funded community clinics also function similarly to large multi- specialty physician groups. Because there is no generally agreed-upon definition of an IDS, it is dif- ficult to provide an exact count of the number of IDSs in existence today. More readily available, however, are data on medical groups, and as noted above, the core of an IDS is a large, multispecialty medical group, whether it is public or private. According to the U.S. Department of Health and Human Services (HHS), in 2003-2004 (the most recent year for which complete data are available), there were 311,200 office-based physicians in the United States practicing in 161,200 medical practices (Hing and Burt, 2007). As previously noted, physicians in solo or small group practices (2 to 10 physicians) make up fully 99 percent of the physicians in office-based physician practices and 89 percent of the physicians in the United States. Therefore, physicians who are the focus of this sector—those in larger groups—constitute only 1 percent of practices and 11 percent of physicians. Nearly 79 percent of physicians are in solo practice or single-specialty groups, whereas only 21 percent are in multispecialty groups. Although the percentage of physicians in large or multispecialty groups, or both, seems small, these physicians do care for a significant percentage of the U.S. population. For example, the members of the American Medical Group Association care for more than 50 million Americans (American Medical Group Association, 2007). Hospitals Hospitals and hospital systems comprise another important part of the healthcare delivery organizations sector. As stand-alone entities or 2For a list of Council of Accountable Physician Practices members, see www.amga.org/CAPP.

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE as part of healthcare systems or networks, public and private hospitals account for about 30 percent of the expenditures on health care in the United States (California HealthCare Foundation, 2006). The following data on hospitals are from the American Hospital Association (2007). There are nearly 5,800 hospitals in the United States, most of which are classified as community hospitals (nonfederal, short-term general, and other specialty hospitals, such as cancer centers or orthopedic specialty centers, including academic medical centers, fit these criteria). More than 80 percent of community hospitals are not for profit or public (state and local). About 2,700 community hospitals are part of a “system,” defined by the American Hospital Association as “a multihospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or managed under contract by a central orga- nization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more and at least 25 percent of their owned or leased nonhospital preacute or postacute healthcare organiza- tions.” About 1,400 community hospitals are part of a “network,” defined by the American Hospital Association as “a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community.” By these definitions, systems and networks are not mutually exclusive: an entity can be classified as both part of a system and part of a network (American Hospital Association, 2007). As defined by the National Association of Public Hospitals and Health Systems (2006), safety net hospitals “include healthcare providers owned and operated by cities, counties, states, universities, non-profit organiza- tions, or other entities” that have “a common . . . mission of providing health care to all, regardless of ability to pay.” In addition to inpatient care, many safety net hospitals also deliver outpatient care. On average, the 100 members of the National Association of Public Hospitals and Health Systems take care of the individuals involved in more than 400,000 ambulatory care visits per year, or approximately 36 percent of outpatient visits in the safety net. Hospitals and hospital systems are clearly not a homogeneous group, and their differences have bearing on their current and future roles in pro- moting the goals of the IOM’s Roundtable on Evidence-Based Medicine. Although the definition is not comprehensive, use of the following defini- tions is one useful way to parse hospitals and hospital systems when their role in the generation and use of evidence is considered: (1) integrated hospital systems comprise hospitals that are closely integrated with multi- specialty medical groups (such as the Mayo Clinic and Kaiser Permanente), (2) academic medical centers are integrated with medical schools, and

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS (3) nonprofit or for-profit community hospitals may or may not have affili- ations with other hospitals or a network. The VHA hospitals represent a fourth category, as they combine aspects of the first two categories provided above. Another way to categorize hospitals is by the organizations that they choose to represent them at the national level, such as the American Hos- pital Association, the Federation of American Hospitals, and the National Association of Public Hospitals and Health Systems. Each broad category of hospitals has different types of incentives and infrastructures for the generation and use of evidence, which will be discussed in more detail in subsequent sections of this chapter. ACTIVITY CATEGORIES Many experts believe that healthcare delivery organizations, including hospitals, are better positioned than physicians in solo and small group practices to generate and use evidence in clinical decision making (Casalino et al., 2003a; Crosson, 2005; Enthoven and Tollen, 2005). Ultimately, they accomplish this by developing evidence-based practice guidelines and mak- ing them available to providers at the point of care. According to Berwick and Jain (2004), doing this requires a number of support systems that can “(1) find the science, (2) embed the science in sound standards of practice, (3) make the relevant knowledge available to clinicians and patients at the point of care and at the time of care, and (4) track performance and improve it continually.” They also note that in creating such systems, “pre- paid group practices are at the forefront.” That statement can be expanded to include not just prepaid group practices but also large IDSs, large physi- cian group practices (prepaid or not), and sophisticated hospitals. How do healthcare delivery organizations develop the four systems described by Berwick and Jain? On the basis of the responses from the inter- views, the primary mechanisms that these organizations use are described below. Information Technology As noted earlier, the aggregation of data across care settings and time is critical to the generation of evidence, and large delivery organizations have an advantage in this area for three reasons: (1) they have a sufficient patient base to support the meaningful (statistically relevant) aggregation of data; (2) they are more likely to have the resources required to implement and maintain the electronic data systems that are necessary for data aggregation and the provision of real-time decision support to clinicians; and (3) in the case of integrated systems, they have access to data from the many settings in which patients receive care.

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE According to Jha and colleagues (2006), although there is no univer- sally accepted definition of the EHR, “consensus is emerging that electronic documentation of providers’ notes, electronic viewing of laboratory and radiology results, and electronic prescribing are key components of an EHR.” These tools facilitate the use of evidence-based practice because they provide clinicians with decision support (in the form of reminders, order sets, and templates) and current practice guidelines at the point of care.3 However, it is not necessary for all of these elements to be in place for a healthcare delivery organization to benefit from electronic data capture. Disease registries can also provide an important platform for conducting research and implementing evidence-based care by providing information about every patient in a provider’s population with a given condition. Although the use of EHRs is on the rise, only about 25 percent of phy- sicians use them, and among office-based physicians, that number is closer to 19 percent (Jha et al., 2006). Large physician group practices and IDSs have been leaders in implementing EHRs (Halvorson, 2004). In fact, the predominant factor affecting the use of information technology is practice size (Audet et al., 2004). Audet and colleagues (2004) found that 87 percent of physicians in large group practices but only 36 percent of physicians in solo practice have access to electronic test results. Other information technologies follow a similar pattern. Physicians in large group practices are more likely than solo practitioners to use EHRs, receive electronic drug alerts, and use e-mail to communicate with colleagues and patients (Audet et al., 2004). Evidence on the use of EHRs in the inpatient setting is lacking. One systematic review of surveys on the adoption of EHRs found that the only higher-quality studies in the inpatient setting focused exclusively on com- puterized physician order entry (CPOE), or electronic prescribing, which is just one component of an EHR. That review concluded that just 5 percent of hospitals use CPOE and that no high-quality estimate of inpatient EHR use could be made (Jha et al., 2006). Another study that used some of the same source data on CPOE that Jha and colleagues (2006) used found that investment in this technology was more likely in government (nonfederal, in the study of Cutler [2005]) and teaching hospitals than in other types of hospitals, with for-profit hospitals being the least likely, and that larger hospitals were more likely than others to invest in CPOE (Cutler, 2005). As with integrated systems and large physician group practices, hos- pital investment in information technology supports the generation and 3 Itshould be noted, however, that if the guidelines available through the EHR are not themselves evidence based, the EHR will do little to improve practice. The EHR is only a tool to convey information; other processes must be in place to ensure that the information is evidence based.

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS use of evidence. Given the limited use of EHRs in hospitals at present, this potential is far from being realized. Different types of hospitals may have various incentives and capabilities to implement EHRs. Integrated hospital systems likely have the greatest capacity and incentive to invest in EHRs because of the economies of scale and the purchasing power of a larger system and because of their ability to share best practices about implementing the technology. Prepaid integrated hospital systems may have additional capacities and incentives to invest in these technologies because of global budgets. Academic medical centers may have incentives to create such systems to remain on the cutting edge and to enable better research and training, but they would typically not enjoy the same incentives as the prepaid integrated systems. Other nonprofit and for-profit community hospitals typically have less of a capability or incentive to purchase and implement large-scale information systems because of an inability to spread costs over their smaller institutions. In a practice or hospital setting not supported by information tech- nology, providers must rely on their memories to keep up with best prac- tices. This is a nearly impossible task when one considers that the results of 10,000 RCTs are published each year (Chassin, 1998). According to David Eddy (1999), a leader in the field of evidence-based medicine, “The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.” However, having an EHR does not guarantee support for evidence-based practice. The structure—and, therein, the utility—of the data repository is important in determining how much providers can learn in real time. Issues that play a role in maximizing the usefulness of electronic data include which data are captured in the clini- cal information system, which data are captured as free-text notes that may not be searchable versus which data are captured as defined fields that are searchable, and whether individual data systems are connected to one another to give a comprehensive picture of a patient’s clinical situ- ation across practice settings. Significant Research Capacity The large patient populations that healthcare delivery organizations serve provide a foundation for conducting research to support evidence- based guidelines. According to Fink and Greenlick (2004), before the 1950s, little was known about the use of health services by noninstitutionalized populations. At about that time, the emergence of several IDSs as a source of care for large populations provided an unprecedented opportunity for research across the full spectrum of care. Some of the pioneering IDSs that established research centers include Kaiser Permanente, the HIP Health Plan of New York, and the VHA.

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE Today, Kaiser Permanente’s eight research centers together comprise one of the largest nonacademic research institutions in the United States (Kaiser Permanente, 2007b). Similar to the Kaiser and HIP research pro- grams, the Mayo Clinic’s Department of Health Services Research also evolved out of large-scale epidemiological projects, including the Olmsted County project, the medical information (medical records, laboratory test and radiological examination results, and tissue specimens) from which the Mayo Clinic has retained for more than 50 years. This information has been the basis of many large-scale observational studies that have led to the development of new knowledge, supporting the Mayo Clinic’s clinical practice, education programs, and research. The VHA also has an expansive national research program, with studies being conducted at more than 100 medical centers on topics that include mental illness, long-term care, traumatic injury, and special populations, such as female veterans. VHA research has made direct contributions to current clinical practices for hypertension, posttraumatic stress disorder, diabetes, and other chronic diseases. The VHA has established a unique program, the Quality Enhancement Research Initiative, whose mission is to bring researchers into partnership with healthcare system leaders to ensure that the care provided is based on the most current scientific evidence, thereby bringing scientific discovery from the bedside to the bench and then back to the bedside (Francis and Perlin, 2006). In collaborating with external, academic research institutions, the VHA can serve as a model for other healthcare system-based research organizations. In addition to these system-specific research centers, many healthcare delivery organizations have joined together in various networks to pool research data and capabilities. Examples include the HMO Research Net- work and the Cancer Research Network.4 All of these research institutions can provide important insight into evidence-based practice. Systematic Use of External Resources In addition to generating their own research, another means by which healthcare delivery organizations gather evidence for clinical decision mak- ing is by availing themselves of external resources. Many healthcare delivery organizations have standing internal technology assessment committees or 4 Members of the HMO Research Network include seven regions of Kaiser Permanente, HealthPartners Research Foundation, Group Health Cooperative, Harvard Pilgrim Health Care, Henry Ford Health System-Health Alliance Plan, Lovelace Clinic Foundation, Meyers Primary Care Institute, Fallon Community Health Plan, Fallon Foundation and the University of Massachusetts Medical School, Scott and White Health System, Geisinger Health System, and Marshfield Clinic Research Foundation. See www.hmoresearchnetwork.org. For informa- tion on the Cancer Research Network, see http://crn.cancer.gov/.

OCR for page 149
9 HEALTHCARE DELIVERY ORGANIZATIONS pharmacy and therapeutics committees whose purposes are to assess all available information on new procedures, devices, and drugs and determine what should be used in practice and how. These committees rely on the inter- nal analysis both of the data and the medical literature and of information from external organizations that provide independent research and analysis, including the Blue Cross Blue Shield Association’s Technology Evaluation Center, Hayes, Inc., UpToDate, ECRI Institute, the Evidence-Based Practice Centers sponsored by the Agency for Healthcare Research and Quality, the Cochrane Collaboration, and the Center for Evidence-Based Policy at the Oregon Health and Science University (Agency for Healthcare Research and Quality, 2007; BlueCross BlueShield Association, 2000; Cochrane Collabo- ration, 2007; ECRI Institute, 2007; Hayes, Inc., 2007; Oregon Health and Science University, 2007; UpToDate, 2007). Quality Measurement and Reporting Critical to the successful implementation of evidence-based practice guidelines is a system of accountability to ensure that the guidelines are being used. One of the ways that healthcare delivery organizations do this is through systematic quality measurement. Because of their size and organizational capacity, such organizations are more likely than smaller practices to have in place quality measurement systems whose capabilities go beyond those required for accreditation. Reporting on the results of the Community Tracking Study survey, Casalino and colleagues (2003b) found that the advantages of medical groups of at least moderate size are their ability to create organized processes to proactively improve care, serve as units of analysis for which statistically reliable and valid measurements of quality can be made, and monitor clinical performance and implement clinical protocols. Hospitals, too, can implement performance measurement and reporting systems within their institutions to help physicians understand how their performance on particular evidence-based quality measures compares with that of their peers. Quality measurement can be used as an internal means of monitoring performance, or it can be tied to financial incentives, as in pay-for-performance programs. If it is done correctly, pay-for-performance can help accelerate the adoption of evidence-based medicine, but to do so, such schemes must reward adherence to evidence-based practice rather than simply reporting on processes. Culture and Leadership An intangible but important element of improving the use of evidence- based clinical decision making is the organizational culture and leadership.

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE with that of their peers. The use of peer pressure as an incentive can be even more effective than the use of financial incentives. When financial incentives are used, they should focus on paying for value and outcomes and not just for performance on process measures. Work by organizations such as the National Committee for Quality Assurance and the Leapfrog Group to standardize performance measures should incorporate concepts of evidence-based decision making. Restructure Financial Incentives The FFS payment system creates incentives to provide care and ser- vices which may or may not be based on evidence-based care. Value-based purchasing initiatives built on foundations of comparative effectiveness research have the potential to correct this problem. As discussed above, pay-for-performance and capitation, types of value-based purchasing, can be important tools if they are structured correctly. However, capitation alone does not encourage the use of evidence-based medicine when the evidence calls for doing more (or more expensive) treatments. Enable Passive Generation of Evidence Even without EHRs, healthcare delivery organizations routinely col- lect a variety of patient care data that could be aggregated by a common entity, such as a payer (e.g., the Centers for Medicare and Medicaid Ser- vices, which has claims data from the vast majority of hospitals and physi- cians). This would add to the ability to use real-time data to learn about best care and would help to bridge the inferential gap that occurs when published research findings are based on data for very narrowly defined populations. Encourage “Systemness” Hospitals and physicians that are parts of systems have a greater abil- ity and more incentives to invest in information technology and to share information on evidence-based care guidelines. Improved collaboration among hospitals and medical staffs, in a variety of organizational forms, will allow the more effective capture and use of evidence. In different geographic areas, different models of hospital-physician collaboration or integration will work better than others, and “systemness” can be either real or virtual. For example, regional health information organizations, which share patient data among the providers in a community, are types of virtual organizations that may prove to be a bridge to improved systemness without full organizational integration.

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS Invest in Understanding the Drivers of Behavior Change Further research is needed to determine which methods work best in changing clinicians’ and patients’ behavior. A large body of literature in the disciplines of sociology and psychology, as well as health services research, has explored this question. Ideas and experts from these fields must be inte- grated more fully into discussions of evidence-based medicine to ensure the use of the most effective means of translating evidence into practice. Advocate for Changes to HIPAA As noted above, the patient privacy provisions of HIPAA have had a chilling effect on the use of large datasets of patient information, even when that information is deidentified. Greater flexibility in the use of patient information for research and quality improvement is needed, provided that the patients’ information is not put at risk of being revealed for other purposes. The IOM is conducting a study, entitled Health Research and the Privacy of Health Information—The HIPAA Privacy Rule, that can serve as a foundation for revisiting HIPAA in light of the need for the improved generation and use of evidence in the everyday delivery of care (Institute of Medicine, 2007). In addition, the high visibility of consumer messages about the right to privacy may have inadvertently created a culture in which consumers do not expect and are not willing to permit data about them- selves to be used for any purpose. More accurate and nuanced messages need to be created for consumers. Improve Collaboration Among End Users As described above in the case studies, many healthcare delivery orga- nizations have processes in place to review internal and external evidence, create clinical guidelines, and translate them into practice. This effort is essential to provide safe, high-quality care but requires significant resources. Today, a sufficient cadre of highly capable entities perform evidence trans- lation, and it may be unnecessary to internally and individually create the capacity. Rather, evidence-based knowledge products (reviews and practice guidelines) can be created jointly by use of a cooperative mechanism. Optimize Human Resources Hospitals and large physician group practices can create infrastruc- tures that fully utilize the expertise that they have within the medical staff. By supporting information exchange and consultation among physicians around emergent or complex medical needs, such as rapid response teams

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE that bring critical care experts to a patient’s bedside within minutes of being called, hospitals can increase best practices and improve outcomes. Similarly, physician organizations, such as the Mayo Clinic, have improved diabetes care by providing the primary care physicians at the clinic in Rochester, Minnesota, virtual consultations with endocrinologists through e-mail. The endocrinologists review an abstract of the EHR and provide performance-triggered suggestions with supporting evidence to the clini- cians and their families. NEXT STEPS Although all of the opportunities described above are important for improving evidence-based decision making, several key initiatives that have the potential to transform the way in which the healthcare delivery organi- zation sector generates and uses evidence have been identified. Create a National Entity to Develop and Disseminate Evidence As noted earlier, there is a need for national agenda setting and coordi- nation of the generation and communication of evidence. An increased and focused investment is also needed. Many large healthcare delivery orga- nizations already do this work independently. National coordination and prioritization would allow the sector as a whole to eliminate redundancy and make better use of the resources devoted to evidence generation. First Step The most important first step for healthcare delivery organizations in creating a national entity for the development and dissemination of evidence is to advocate for this change with policy makers and other stake- holders. Policy makers must be educated about the need for such an entity and encouraged to authorize and establish funding for it. Because of their high visibility and significant clinical expertise, sector members must play a central role in efforts to design and advocate for the agenda-setting entity. Such work may include active communication of the work of the IOM’s Roundtable on Evidence-Based Medicine. Cross-Sector Collaboration A number of other healthcare sectors are advocating for the entity described here. Rather than working alone or at cross-purposes with these sectors, healthcare delivery organizations should work with the organiza- tions already active in this area as they develop a vision and legislation to

OCR for page 149
9 HEALTHCARE DELIVERY ORGANIZATIONS authorize the entity. Some of the organizations taking a lead in this area include America’s Health Insurance Plans, the BlueCross BlueShield Asso- ciation, the Health Industry Forum, and AcademyHealth. These existing efforts could benefit from the clinical and research expertise of the large healthcare delivery organizations. Support the Adoption and Use of Information Technology The broader implementation of EHRs across the entire healthcare delivery organization sector will both support the delivery of care and create rapid-learning organizations. The digitization of healthcare delivery through the use of the EHR is one of the most important changes that can be made to improve care and support learning. Large delivery organiza- tions, in addition to leading this change, can also help smaller physician groups learn about EHRs by providing technical assistance and sharing their expertise through the establishment of learning networks. Unless all (or nearly all) healthcare providers can connect and share information elec- tronically, there will continue to be a significant amount of information lost and missed opportunities for learning. It is therefore critical that the digital divide be closed. Healthcare delivery organizations can play a leadership role in making this happen. First Steps One of the major barriers to the widespread adoption of EHRs is a lack of standardization of the data produced by clinical information systems. The federal government is in the best position to convene stakeholders to establish these needed standards and to enforce adherence to the standards, once they are established. However, as noted above, healthcare delivery organizations are leaders in the implementation of EHRs and therefore have a wealth of expertise that can and should be brought to bear on efforts to create interoperability and other information technology standards. This sector can also be a leader in establishing learning networks of organiza- tions that have implemented EHRs to disseminate knowledge to all pro- viders, both organized and nonorganized. Cross-Sector Collaboration The federal government is leading the way in standard setting for health information technology interoperability. In 2005, HHS announced the formation of the American Health Information Community (AHIC), which will provide input and recommendations to HHS on how to make health records digital and interoperable and ensure that the privacy and

OCR for page 149
0 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE security of those records are protected (U.S. Department of Health and Human Services, 2007). Initially, HHS appointed 16 members, including a few representing healthcare delivery organizations, to the AHIC com- mission. Plans are now being made to transition AHIC to an independent and sustainable public–private partnership by fall 2008. Because of their expertise with these systems and their significant financial investments in them, healthcare delivery organizations should take every opportunity to participate in this and other processes that support standardization. Healthcare delivery organizations should also continue to collaborate with the federal government in this area by participating in various Medicare demonstration projects to test and measure the effect of program changes on the adoption and use of healthcare information technology (primarily in the FFS delivery system). Improve Understanding of and Support for Evidence-Based Care The concept of evidence-based medicine and its potential to drastically improve quality need to be communicated broadly to the public in much the same way as the concept of medical errors and the opportunities to make health care safer were communicated when the IOM published To Err Is Human in 1999 (Institute of Medicine, 1999). Many of the opportunities identified above call for educating key stakeholders (clinical leaders, rank- and-file clinicians, boards of directors of healthcare delivery organizations, and patients-consumers) about the need for the improved use of evidence- based decision making and outlining some potential strategies for doing so. As these strategies make clear, there is no single way to reach all of these audiences with messages about evidence-based care; multiple channels will need to be used. As entities with many opportunities to reach both patients and providers, healthcare delivery organizations have a unique opportunity to develop and deliver messages about the importance of evidence-based care to these audiences. First Steps Although the strategies for reaching the main stakeholders differ, the healthcare delivery organizations sector has unique access to all of these groups and therefore a unique potential to influence them. As a first step toward improving the understanding of and support for evidence-based care, healthcare delivery organizations should work collaboratively to develop the messages, materials, or curricula to be used with key audiences and then work independently to influence their own boards, clinical leaders, clinicians, and patients. To make such an education part of the culture of medicine and the delivery of care and to influence the public in a more

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS meaningful way, longer-term strategies involving the efforts and resources of multiple sectors (including the media) will be necessary. Cross-Sector Collaboration Collaboration across healthcare sectors and beyond will be critical to improving the understanding of and support for evidence-based care. For example, the healthcare professions education sector and professional soci- eties and associations will need to play active roles in efforts to change the training of clinicians (and clinician leaders). The consumer sector will need to collaborate with healthcare delivery organizations, insurers, and others out- side of traditional healthcare circles (including the broader public education sector) to include information on evidence-based care in health education, in public awareness campaigns, and through health insurance benefit design. There may be a role for an entity such as the IOM to organize and facilitate this work, given the cross-sector collaboration required. Link Measures of Evidence-Based Care to Performance Standards and Incentives Performance measurements and incentives need to be structured to encourage the use of evidence-based care. Healthcare delivery organizations can play an important role in this work by identifying care standards based on the evidence and structuring incentives (such as payment differentials) to reward value and outcomes. This can help place a focus on the most important standards and narrow the range of different requirements from different payers. A lack of consistent pay-for-performance expectations has been shown to reduce the impacts of these programs. First Steps Healthcare delivery organizations should review their existing perfor- mance measures and care standards to assess the extent to which they are already evidence based. Measures and standards that are evidence based should be prioritized, and those that are not should be considered for adaptation or elimination. In addition, healthcare delivery organizations should examine their existing internal payment incentives (such as provider bonuses) to ensure that they are paying for evidence-based care. Cross-Sector Collaboration A number of sectors will need to be involved in efforts to align perfor- mance measurement and incentives with evidence-based care. For example,

OCR for page 149
2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE as noted earlier, organizations such as the National Committee for Quality Assurance and the Leapfrog Group can set the standard for creating per- formance measures based on evidence, and purchasers can adopt more consistent evidence-based standards. The Agency for Healthcare Research and Quality should also play a role in this work. Although healthcare delivery organizations can serve as subject matter experts and learning laboratories for testing measurement and incentive approaches, the national entities described above are in a better position to standardize measures and approaches to providing incentives across organizations. In addition, employers and large public purchasers should play a central role in creating value-based purchasing initiatives (such as pay for performance) that align incentives for medical care to adhere to the evidence. Conclusion The healthcare delivery organizations sector plays a central role in efforts to improve the use of evidence-based care. As entities that organize and employ physicians and other clinicians, deliver care to patients, and, in some cases, conduct research, sector members have opportunities to influ- ence the generation and use of evidence through many channels. Because sector members are organized and can act purposefully as goal-setting institutions, they may have a greater ability than nonorganized providers to influence the transformational initiatives outlined above. Momentum is building nationally to improve the use of evidence-based care, and now is the time for healthcare delivery organizations to take action to assist in this effort. Change will not come overnight, nor will it come from only one sector. Reasonable goals for the healthcare delivery organizations sector in the next 3 to 5 years include working with others to accomplish the following: enact authorizing legislation for a national entity to develop and disseminate evidence, develop widely accepted standards for informa- tion technology interoperability, begin a public outreach and awareness campaign about evidence-based medicine, and standardize and streamline quality measurement and incentive programs to focus resources on a defined set of evidence-based practices. Sector members can also provide leadership in efforts to improve the use of evidence-based care by modeling what works for nonorganized providers. To date, as examined in the case studies presented earlier in this chapter, many healthcare delivery organizations are already active in this arena. By providing models of effective generation and use of the evidence, healthcare delivery organizations can help nonorganized providers better understand the quality benefits of integration and organization, which could ultimately encourage the spread of evidence-based care.

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS REFERENCES Agency for Healthcare Research and Quality. 2007. Evidence-based practice centers. http:// www.ahrq.gov/clinic/epc/ (accessed August 31, 2007). Alliance of Community Health Plans. 2007. Alliance of Community Health Plans website. http://www.achp.org/ (accessed April 30, 2008). American Diabetes Association. 2007. Diabetes personal health decisions (PHD). http://www. diabetes.org/diabetesphd/default.jsp (accessed April 30, 2008). American Hospital Association. 2007. Fast facts on U.S. hospitals. http://www.aha.org/aha/ resource-center/Statistics-and-Studies/fast-facts.html (accessed March 22, 2007). American Medical Group Association. 2007. American Medical Group Association website. http://www.amga.org/ (accessed April 30, 2008). Archimedes-Kaiser Permanente. 2007. The Archimedes model. http://archimedesmodel.com/ archimedes.htm (accessed April 30, 2008). Asch, S., E. McGlynn, M. Hogan, R. Hayward, P. Shekelle, L. Rubenstein, J. Keesey, J. Adams, and E. Kerr. 2004. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 141(12):938-945. Audet, A. M., M. M. Doty, J. Peugh, J. Shamasdin, K. Zapert, and S. Schoenbaum. 2004. Information technologies: when will they make it into physicians’ black bags? MedGenMed: Medscape General Medicine 6(4):2. Berenson, R. A., P. B. Ginsburg, and J. H. May. 2007. Hospital-physicians relations: Coopera- tion, competition, or separation? Health Affairs 26(1):w31-w43. Berwick, D. M., and S. H. Jain. 2004. Systems and results: The basis for quality care in prepaid group practice. In Toward a 2st century health system: The contributions and promise of prepaid group practice, edited by A. Enthoven and L. Tollen. San Francisco, CA: Jossey-Bass. BlueCross BlueShield Association. 2000. Technology evaluation center. http://www.bcbs. com/betterknowledge/tec/ (accessed April 30, 2008). Brown, S. H., M. J. Lincoln, P. J. Groen, and R. M. Kolodner. 2003. Vista—U.S. Department of Veterans Affairs national-scale HIS. International Journal of Medical Informatics 69(2-3):135-156. Burt, C. W., and J. E. Sisk. 2005. Which physicians and practices are using electronic medical records? Health Affairs 24(5):1334-1343. California HealthCare Foundation. 2006. Snapshot: Health care costs 0. http://www.chcf. org/documents/insurance/HealthCareCosts06.pdf (accessed March 22, 2007). Casalino, L., R. R. Gillies, S. M. Shortell, J. A. Schmittdiel, T. Bodenheimer, J. C. Robinson, T. o, Rundall, N. Oswald, H. Schauffler, and M. C. Wang. 2003a. External incentives, infor- infor- mation technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA 289(4):434-441. Casalino, L. P., K. J. Devers, T. K. Lake, M. Reed, and J. J. Stoddard. 2003b. Benefits of and barriers to large medical group practice in the United States. Archives of Internal Medi- cine 163(16):1958-1964. Chassin, M. R. 1998. Is health care ready for six sigma quality? Milbank Quarterly 76(4):510, 565-591. Cochrane Collaboration. 2007. The Cochrane Collaboration website. http://www.cochrane. org/ (accessed April 30, 2008). Council of Accountable Physician Practices. 2007. Better together. http://www.amga.org/ CAPP (accessed April 30, 2008). Crosson, F. J. 2005. The delivery system matters. Health Affairs 24(6):1543-1548.

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE Crosson, F., A. Weiland, and B. Berenson. 2004. Physician leadership: “group responsibility” as key to accountability in medicine. In Toward a 2st century health system: The con- tributions and promise of prepaid group practice, edited by A. Enthoven and L. Tollen, San Francisco, CA: Jossey-Bass. Cutler, D. M., N. E. Feldman, and J. R. Horwitz. 2005. U.S. adoption of computerized physi- cian order entry systems. Health Affairs (Millwood) 24(6):1654-1663. ECRI Institute. 2007. ECRI Institute website. http://www.ecri.org/Pages/default.aspx (accessed November 2007). Eddy, D. M. 1999. Issues in Permanente medicine: Evidence-based medicine. San Francisco, CA: Permanente Federation. ———. 2007. Linking electronic medical records to large-scale simulation models: Can we put rapid learning on turbo? Health Affairs 26(2):w125-w136. Enthoven, A. C., and L. A. Tollen. 2005. Competition in health care: It takes systems to pursue quality and efficiency. Health Affairs Suppl. Web Exclusives:W5-420–W5-433. Etheredge, L. M. 2007. A rapid-learning health system. Health Affairs 26(2):w107-w118. Fink, R., and M. Greenlick. 2004. Prepaid group practice and health care research. In Toward a 2st century health system: The contributions and promise of prepaid group practice, edited by A. Enthoven and L. Tollen. San Francisco, CA: Jossey-Bass. Francis, J., and J. B. Perlin. 2006. Improving performance through knowledge translation in the veterans health administration. Journal of Continuing Education in the Health Professions 26(1):63-71. Greenfield, S., and S. H. Kaplan. 2004. Creating a culture of quality: The remarkable trans- formation of the Department of Veterans Affairs health care system. Annals of Internal Medicine 141(4):316-318. Halvorson, G. 2004. Prepaid group practice and computerized caregiver support tools. In Toward a 2st century health system: The contributions and promise of prepaid group practice, edited by A. Enthoven and L. Tollen. San Francisco, CA: Jossey-Bass. Hayes, Inc. 2007. Hayes, Inc. website. http://www.hayesinc.com/hayes/ (accessed April 30, 2008). Hing, E., and C. W. Burt. 2007. Office-based medical practices: Methods and estimates from the national ambulatory medical care survey. Advance Data (383):1-15. Institute for Clinical Systems Improvement. 2007. Institute for Clinical Systems Improvement website. http://www.icsi.org/ (accessed November 2007). Institute of Medicine. 1999. To err is human. Washington, DC: National Academy Press. ———. 2001. Crossing the quality chasm: A new health system for the 2st century. Wash- ington, DC: National Academy Press. ———. 2005. Building a better delivery system: A new engineering/health care partnership. Washington, DC: The National Academies Press. ———. 2007. Health research and the privacy of health information—The HIPAA privacy rule. http://www.iom.edu/CMS/3740/43729.aspx (accessed November 2007). IOM Roundtable on Evidence-Based Medicine. 2006. Charter and vision statement: Round- table on Evidence-Based Medicine. Washington, DC. Jha, A. K., J. B. Perlin, K. W. Kizer, and R. A. Dudley. 2003. Effect of the transformation of the Veterans Affairs health care system on the quality of care. New England Journal of Medicine 348(22):2218-2227. Jha, A. K., T. G. Ferris, K. Donelan, C. DesRoches, A. Shields, S. Rosenbaum, and D. Blumenthal. 2006. How common are electronic health records in the United States? A summary of the evidence. Health Affairs 25(6):w496-w507. Kaiser Permanente. 2007a. KP healthconnect. http://www.kphealthconnectq4update.org/ index.html (accessed November 2007).

OCR for page 149
 HEALTHCARE DELIVERY ORGANIZATIONS ———. 2007b. Medical research at Kaiser Permanente. http://newsmedia.kaiserpermanente. org/kpweb/ourmedicalres/entrypage.do (accessed November 2007). Kerr, E. A., D. M. Smith, M. M. Hogan, T. P. Hofer, S. L. Krein, M. Bermann, and R. A. Hayward. 2003. Building a better quality measure: Are some patients with “poor qual- ity” actually getting good care? Medical Care 41(10):1173-1182. Kupersmith, J., J. Francis, E. Kerr, S. Krein, L. Pogach, R. M. Kolodner, and J. B. Perlin. 2007. Advancing evidence-based care for diabetes: Lessons from the Veterans Health Administration. Health Affairs 26(2):w156-w168. Landon, B., L. Hicks, A. O’Malley, T. Lieu, T. Keegan, B. McNeil, and E. Guadagnoli. 2007. Improving the management of chronic disease at community health centers. New England Journal of Medicine 356(9):921-934. Lerner, L. 2007. Hospitals providing financial assistance to staff physicians involving elec- tronic health records. Internal Revenue Service memorandum. Washington, DC: Internal Revenue Service. McGlynn, E., S. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. Kerr. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348(26):2635-2645. National Association of Public Hospitals and Health Systems. 2004. America’s public hos- pitals and health systems, 200: Results of the NAPH annual hospital characteristics survey. http://www.naph.org/Content/ContentGroups/Publications1/Characteristics2004. pdf (accessed March 22, 2007). Oregon Health and Science University. 2007. Center for evidence-based policy. http://www. ohsu.edu/policycenter/ (accessed April 30, 2008). Perlin, J. 2006. Transformation of the U.S. Veterans Health Administration. Health Economics, Policy, and Law 1(2):99-105. Serb, C. 2007. Stark redo. Hospitals hesitate to help digitize doctors’ offices until the “re- laxed” rules are further clarified. Hospitals and Health Networks 81(2):32, 34-36, 38. Stewart, W. F., N. R. Shah, M. J. Selna, R. A. Paulus, and J. M. Walker. 2007. Bridging the inferential gap: The electronic health record and clinical evidence. Health Affairs 26(2): w181-w191. UpToDate. 2007. UpToDate website. http://www.uptodate.com/ (accessed April 30, 2008). U.S. Department of Health and Human Services. 2007. American health information commu- nity. http://www.hhs.gov/healthit/community/background/ (accessed April 30, 2008). INTERVIEWEES The interviewees included Madhulika Agarwal, Chief Patient Care Services Officer, Veterans Health Administration; Ahmed Calvo, Medical Advisor, Center for Quality, Health Resources and Services Administra- tion; Denis Cortese, President and Chief Executive Officer, Mayo Clinic; Roscoe Dandy, Office of Minority Health and Health Disparities, Health Resources and Services Administration; Carolyn Days-Mustille, Codirector, Kaiser Permanente Care Management Institute; Benjamin Druss, Rosalynn Carter Chair in Mental Health and Associate Professor of Health Policy and Management, Rollins School of Public Health, Emory University; Kay Felix-Aaron, Director, Office of Quality Data, Center for Quality, Health Resources and Services Administration; Nancy Foster, Vice President for Quality and Patient Safety, American Hospital Association; Denise Geolot,

OCR for page 149
 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE Director, Center for Quality, Health Resources and Services Administration; Steve Mayfield, Director, American Hospital Association Quality Center; Gregg Meyer, Medical Director, Massachusetts General Physician Organi- zation (MGPO) and Senior Vice President for Quality and Patient Safety, Massachusetts General Hospital and MGPO; Lynnette Nilan, Office of Patient Care Services, U.S. Department of Veterans Affairs; Jonathan Perlin, Chief Medical Officer and President, Clinical Services, HCA, Inc.; Richard Platt, Professor and Chair, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care; Paul Wallace, Medical Director for Health and Productivity Management Programs, The Permanente Federation; Deborah Willis-Fillinger, Senior Medical Advisor, Center for Quality, Health Resources and Services Administration; and Scott Young, Codirector, Kaiser Permanente Care Management Institute.