Leadership Commitments to Improve Value in Health Care Finding Common Ground: Workshop Summary (2009) / Chapter Skim
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7 Healthcare Delivery Organizations
7 Healthcare Delivery Organizations
Pages 149-186
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From page 149... ...
. 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.
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. 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 organizations.1 Over the course of these interviews, two general themes emerged: (1)
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. Another example is the Veterans Health Information Systems and Technology Architecture (VistA)
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, 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.
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. Hospitals Hospitals and hospital systems comprise another important part of the healthcare delivery organizations sector.
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Although the definition is not comprehensive, use of the following definitions 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 multispecialty medical groups (such as the Mayo Clinic and Kaiser Permanente)
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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)
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. As with integrated systems and large physician group practices, hospital 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.
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Issues that play a role in maximizing the usefulness of electronic data include which data are captured in the clinical 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 situation across practice settings. Significant Research Capacity The large patient populations that healthcare delivery organizations serve provide a foundation for conducting research to support evidencebased guidelines.
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Systematic Use of External Resources In addition to generating their own research, another means by which healthcare delivery organizations gather evidence for clinical decision making 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.
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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.
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Case Studies The following case studies illustrate the ways in which healthcare delivery organizations have incorporated the practices described above
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These practices include programs for mailed prescriptions, group visits, phone consultations with pharmacists, electronic reminders for physicians, tools for panel management support, patient coaching outside of the office, and the involvement of the entire healthcare team. From 2002 to 2005, the proportions of members with coronary artery disease and those over age 55 years with diabetes who took the ALL medications increased from 49 to 67 percent (personal communication, Michelle Wong, Kaiser Permanente Care Management Institute, 2007)
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Safety net clinics were early adopters of the notion of evidence-based practice and quality improvement processes, as demonstrated by a partnership with the Institute for Healthcare Improvement to form Health Disparities Collaboratives, which began in 1998. This evidence-based systems change initiative is, at its core, a quality improvement effort based on known quality deficiencies in the treatment of chronic diseases and cancer and in the prevention of these diseases.
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This measurement will enable the identification of model programs that can be disseminated elsewhere and can provide centers with information on comparable patient populations. Veterans Health Administration As the largest public IDS in the United States, the VHA annually serves 5.3 million patients at nearly 1,400 sites of care (Kupersmith et al., 2007)
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. Mayo Clinic The Mayo Clinic has a long and distinguished history as a leader in the provision of high-quality health care and as a learning organization through its use of core strategies of integrated medical practice, education, and research, all underpinned by the provision of information in an accurate, timely, and reliable manner.
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Founded in 1993 by HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services, the Institute for Clinical Systems Improvement today has 62 members and is funded by all six health plans in Minnesota. The medical groups and hospital systems combined represent more than 7,600 physicians (Institute for Clinical Systems Improvement, 2007)
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The model has been validated against existing real-world clinical trials by simulating the different components of those trials and comparing the results of the simulation to the results of the actual trial itself (Archimedes-Kaiser Permanente, 2007)
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, syndromes that affect multiple organ systems, drugs that have multiple effects, and combinations of drugs; address questions of timing, such as screening, frequency of follow-up visits, or how long a medication should be tried before the dose is changed; and help design and predict clinical trials. Eddy and Schlessinger developed the Archimedes model with major support from Kaiser Permanente, and the model is now available to all researchers and healthcare delivery organizations.
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. Significant expansions in the availability and use of information technology will be necessary to bridge this digital divide and to reach the Roundtable's goal of having 90 percent of clinical decisions be evidence based by 2020.
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The best methods of changing physician behavior are not yet known. Research has shown that the provision of didactic continuing medical education courses is not effective in changing behavior, and more participatory forms of continuing medical education (e.g., rounds)
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Followership Practices Although greater leadership is needed to advance the practice of evidence-based medicine, rank-and-file practitioners also need a more thorough understanding of the concept. Many experts interviewed for this statement believe that outside of highly academic and elite health and medical policy circles, there is little discussion of the implications of evidence for clinical decision making or understanding that much of current practice is not, in fact, evidence based.
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Multiple Payers and Reporting Requirements As noted above, quality measurement and reporting are means by which large healthcare delivery organizations can improve their use of evidence-based decision making. However, large providers are often subject to multiple and conflicting reporting demands from different payers.
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A lack of resources can also make referrals to specialists difficult, even when the best evidence clearly calls for it. In addition, the multiple comorbidities and poor socioeconomic condition of many individuals who comprise the safety net patient population add to the problem of the inferential gap described earlier.
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Support Information Technology and Identify Strategies to Eliminate the Digital Divide To improve the generation and use of evidence, more healthcare delivery organizations must implement fully operational EHRs with decision sup
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Remedying this problem, essentially undoing the learning that health care is delivered one patient at a time, will require the training of clinician leaders in new fields, such as systems and industrial engineering and the management of organizational change. Leaders need to be reoriented to view healthcare organizations as having a collective responsibility for groups of patients.
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Another means of creating consumer demand for evidencebased medicine is to design insurance benefit packages that require smaller amounts of cost-sharing for evidence-based care than for other types of care.5 The science of evidence-based medicine may not yet allow this to happen on a broad scale, but as the science develops, so, too, can consumer incentives. Link Performance Standards to Use of Evidence Healthcare delivery organizations can and must identify standards of care and measure individual physicians' performance against them.
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treatments. Enable Passive Generation of Evidence Even without EHRs, healthcare delivery organizations routinely collect 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 Services, which has claims data from the vast majority of hospitals and physicians)
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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 organizations have processes in place to review internal and external evidence, create clinical guidelines, and translate them into practice.
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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 stakeholders. Policy makers must be educated about the need for such an entity and encouraged to authorize and establish funding for it.
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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.
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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.
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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 performance measures and care standards to assess the extent to which they are already evidence based.
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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 information 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.
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. Archimedes-Kaiser Permanente.
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:w496-w507. Kaiser Permanente.
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. 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 Administration; 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,
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From page 186... ...
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.
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