Pathology: Brief History

Transcription

1 Medical Homes Role in Advancing Integrated Patient Care and How Clinical Labs Add Value James M. Crawford, M.D., Ph.D. Department of Pathology and Laboratory Medicine North Shore-Long Island Jewish Health System Hofstra North Shore-LIJ School of Medicine Pathology: Brief History Birth of modern Pathology/Laboratory Medicine Vast enhancement of Population Health Birth of modern Medical Practice Establishment of effective therapies Age of the National Institutes of Health Spectacular advances by Investigative Pathology Pivot into Translational Research Evidence of effective outcomes? Development of Personalized Medicine? Leadership in Patient-Centered Care? Leadership in Population Health? Leadership in Learning Health Systems? Leadership in Value-Based Physician Networks?

2 For each generation: It is our watch. The forces in motion now will determine the trajectory of our specialty for generations of Pathologists that follow us. The Challenge How does Pathology turn the corner on Primary Care, Access and Population Health?

3 Population-based Healthcare Outcomes MEDICAL SCIENCE ACCESS Patient Centered Medical Home HIT Personalized Medicine The National Environment 3/2009: American Recovery and Reinvestment Act HITEC 3/2010: Patient Protection and Affordable Care Act ACO Electronic Health Records Physician Network Consolidation

4 Page 354: American Recovery and Reinvestment Act 2009 (C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS. (i) IN GENERAL. No incentive payment may be made under this paragraph in the case of a hospitalbased eligible professional. (ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL. For purposes of clause (i), the term hospitalbased eligible professional means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider. Enter the concepts of: Patient Centered Medical Home Advanced Medical Home Patient Centered Medical Neighborhood

5 Patient Centered Medical Home Advanced Medical Home Primary Care Practice Specialists delivering primary care Patient Centered Medical Neighborhood Continuity of care through all delivery sites PCMH: Definition An approach to providing comprehensive primary care through a healthcare setting that facilitates partnerships between individual patients, their personal physicians, and, when appropriate, the patient s family. Each patient has a personal physician This personal physician directs the primary medical care received by the patient The personal physician takes responsibility for arranging care for all of the patient s health needs The personal physician coordinates the patient s care across all elements of the complex health system

6 Patient Centered Medical Home OPERATIONAL PRINCIPLES* Healthcare quality and safety are integral objectives of a PCMH Patients should have enhanced access to healthcare through the PCMH Payment for healthcare services should recognize the added value provided to patients who have a patient-centered medical home EXPECTATIONS Excessive utilization of healthcare services will be reduced The patient experience will improve Primary Care Providers will have more time to spend with their patients The healthcare outcomes of the population will improve *2007: AAP, ACP, AAFP, AOA PCMH: Brief History 1967 American Academy of Pediatrics (AAP): concept of a chronic care home 2001 Institute of Medicine (IOM) report: Crossing the Quality Chasm: A New Health System for the 21 st Century 2005 Institute of Medicine (IOM) report: Building a Better Delivery System: A New Engineering/Health Care Partnership 2004 American Academy of Family Physicians (AAFP): endorses PCMH 2006 American College of Physicians (ACP): endorses PCMH American Osteopathic Association (AOA): endorses PCMH 2006 Patient Centered Primary Care Collaborative (PCPCC) established 2007 Joint Principles for PCMH articulated by AAP, AAFP, ACP, AOA National Committee for Quality Assurance (NCQA; founded 1990) incorporates Joint Principles into their Physician Practice Connections (PPC) guidelines 2008 NCQA begins deeming physician practices for meeting PPC-PCMH standards 2009 American Recovery and Reinvestment Act (ARRA): $30B of adoption incentives for meaningful use of certified Electronic Health Records (EHR) : Medicare Initiation of numerous Medicare demonstration programs 2010 Patient Protection and Affordable Care Act: Patient-Centered Demonstrations

7 PCMH Activities Enhanced Access Team approach Registries (pop. mgmt) Active care coordination Quality and safety systems Advanced patient engagement Information systems foundation The PCMH requires a new mental model of how primary care delivers value David Nace, 2010

8 Taking care of patients Hours required for full portfolio of care Hours / Day Optional Prevention Patient Education Care Coordination 7.4 hours/day 2 hours/day 2 hours/day Practice improvements often fail because they rely on the willingness of physicians, who are already too busy, to take on additional work. - Tom Bodenheimer 8 Hour Day 4 2 Direct Patient Care 7 hours/day 0 Physician (Based on a panel size of 2500 patients) David Nace, 2010 Patient Centered Medical Home Building a team model Hours/Day Patient Flow Manager Physician Care Manager Midlevel Pharmacist IT David Nace, 2010

9 Patient Centered Medical Home Key Components of a Transformed Practice Comprehensive Care Patient Engagement Enhanced Access Coordinated Care Team of Providers Additional non-physician providers support medical home s ability to provide additional services EHR with Registry Function Provides data around key patient metrics to help track and monitor patients allowing for improved overall patient management David Nace, 2010 The value proposition for the PCMH* INTEGRATED DELIVERY SYSTEMS (for example) Group Health Cooperative of Puget Sound: 0.2% PMPM decrease for PCMH patients; 16% decrease in hospital admissions. Geisiger Health System PCMH model: 7% PMPM decrease for PCMH patients; 18% decrease in hospital admissions. VA Midwest Healthcare Network (VISN 23): 27% decrease in hospital admissions/emergency Department visits HealthPartners Medical Group/BestCare PCMH Model: 8% decrease in overall costs 24% decrease in hospital admissions; 24% decrease in Emergency Department visits Intermountain Healthcare Medical Group Care Management Plus PCMH Model: 25% decrease in hospital admissions for diabetics; $53 PMPM reduction *Grumbach K, Grundy P; 11/16/2010

10 What is the role of Pathology in Patient Centered Healthcare? Patient Centered Medical Home Key Components of a Transformed Practice Comprehensive Care Patient Engagement Enhanced Access Coordinated Care Team of Providers Additional non-physician providers support medical home s ability to provide additional services EHR with Registry Function Provides data around key patient metrics to help track and monitor patients allowing for improved overall patient management David Nace, 2010

11 Patient Centered Medical Home Key Components of a Transformed Practice Comprehensive Care Patient Engagement Enhanced Access Coordinated Care Team of Providers Additional non-physician providers support medical home s ability to provide additional services EHR with Registry Function Provides data around key patient metrics to help track and monitor patients allowing for improved overall patient management David Nace, 2010 Sinard & Morrow, Human Pathol 2001; 32:

12 Patient Centered Health Care Community Home Care Specialists Imaging Employer Patient Rehabilitation Acute Care Labs Insurance ca Patient Centered Health Care Community Home Care Specialists Imaging Employer Patient frustration Rehabilitation Acute Care Labs Insurance ca. 2010

13 The position of the Office of the National Coordinator* It is the local multistakeholder alliances that will effect change. Information is the lifeblood of medicine. Meaningful use is the key to unlocking the potential of Health IT for Primary Care, Specialty Care, and Hospitals, because it focuses not on the technology but on its use. Five domains of focus: - Quality, Safety, Efficacy, Access - Public and Population Health - Engagement of Patients and Families - Coordination of Care - Privacy and Security These domains accord perfectly with the PCMH. *David Blumenthal, 3/30/2010 Patient Centered Medical Home Information Management Requirements Patient Access and Communication Patient Tracking and Registry Care Management appointment scheduling clinical information/phr* education information self-management support organizing clinical data* managing disease conditions* guidelines, Decision Support* electronic prescribing test tracking* tracking referrals tracking Continuum-of-Care* *Pathology: primary data or potential coordinator National Committee for Quality Assurance 2008

14 Patient Centered Medical Home Performance Reporting and Improvement Measures of physician and practice performance* Measures of healthcare outcomes Safety and Quality of healthcare* Specific disease management outcomes* Patient experience and satisfaction (Note: role of Phlebotomy services) Ed note: These tools help the physician practice achieve improved outcomes; they are not construed as a policing function *Pathology: primary data or potential coordinator National Committee for Quality Assurance 2008 Patient Centered Medical Home Patient Management Previsit planning (Laboratory testing*, Radiology testing, Dietary restriction) Patients needing clinical review or action* Monitoring patients on specific medications Patients needing reminders for preventive care, specific tests, follow-up* Patients who might benefit from care management support* *Pathology: primary data or potential coordinator

15 Patient Centered Medical Home Population Management Integrated clinical data from all care sites* Integrated ancillary data (e.g., all laboratory tests, all referrals)* Healthcare Resource utilization Physician office visits, use of ancillaries, need for acute care* Real-time tracking of Claims data* to include use of Pharmaceuticals* Real-time tracking of Safety and Quality Outcomes* Real-time tracking of the Patient Experience* Disease Management Outcomes* Biometrics (e.g., weight, body-mass index, blood pressure)* Laboratory values as primary data on patient status (e.g., HbA1c, lipids)* Data on Lifestyle management (e.g., activities, dietary education)* *Pathology: primary data or potential coordinator Patient Centered Medical Home Clinical Endpoints Resolution of medical condition(s)* Addition of co-morbid or new conditions* Escalation of care environment* Acute-care intervention (e.g., hospitalization, surgery)* Death* *Pathology: primary data or potential coordinator

16 Patient Centered Medical Home Outcomes Assessment Physician Practice outcomes* Testing of Evidence-Based Medicine within your healthcare organization* Testing and validation of Safety and Quality initiatives* Identification of Adverse Events* Patient Compliance* Efficacy of Lifestyle, Wellness, and Disease Management programs* Access to Preventive Screening programs* Delivery of healthcare at lowest cost service location* Return-on-investment of HIT solutions and the PCMH* Data on Lifestyle management (e.g., activities, dietary education)* *Pathology: primary data or potential coordinator Payment issues There is no current payment model for these pathology activities -? Consultation for appropriate test utilization?* -? Access to pathology-specific demonstration projects?* We are excluded by federal law from receiving practice payments. Attribution and Distribution of shared savings is yet to come. When (not if ) Bundled Payments arrive, the allocation of funding will be a local event. Where will Pathology/Lab Medicine be if not already recognized locally for our value proposition in patient management? *College of American Pathologists: current advocacy

17 You can t retrofit Laboratory into the Medical Home/ACO model. You have to be part of the design in order to pre-establish your value. What-if In-Patient EHR Ambulatory EHR Registration and Billing Master Patient Registry Laboratory Information System RHIO Patient Experience Patient Outcomes

18 The Learning Healthcare System (1) EHR Database Biostatistics (2) Research Output (3) Occupational Health (4) Genomics Claims Physicians Patient EHR Record (2.1) Laboratory Data (5) National Benchmarking NSLIJ Current Physician Network Ambulatory Care Network MG PCP* 2010 Outpatient Revenue = 36% Inpatient Revenue = 64% MG Specialties Acuity Affiliated $ $ $ Market Share = <10% Market Share = 26% Hospitals *MG PCP: Medical Group Primary Care Providers

19 NSLIJ Value-Based Physician Network Ambulatory Care Network MG PCP Affiliated Pathology: supporting Physician Offices; sourcing data for network $? MG Specialties Market Share $? Hospitals Department of Pathology and Laboratory Medicine Convergent Objectives: NSLIJ HS: Ambulatory EHR Ambulatory Care Network AllScripts NSLIJ Laboratories: uniform Laboratory Information System Integration of service units Integrated business/leadership model ATLAS, Other NSLIJ HS Physician Practices Outreach Physician Practices Patient-Centered Quality Outcomes Penetration of market Population-based Improved Healthcare

20 Find the strongest signal in your local healthcare environment Work with those stakeholders. Make your own business future. The Role of Pathology/Lab Med Primary informant on absolute measures of health status. Colleague to physicians across the continuum-of-care: - Mastery of disease pathobiology - Medical Director of all clinical diagnostics to include: advanced diagnostics of Personalized Medicine - first Providers to see the data readouts - Responsible for the largest single source of medical data - Expert on data analytics, population outcomes System expert in effective delivery of healthcare resources. Get involved locally: Health System Ambulatory Care Network Primary Care Physician Practices Civic agencies, local employers

21 The Message Pathologists should actively seek participation in demonstration pilots: PCMH, Coordinated Care, EHR (and PHR) deployment. Pathologists should be drivers of EHR (and PHR) data flow. Pathologists, as integral members of the Coordinated Care Team, should be experts on test selection and interpretation for individual patients. Pathologists should inform regional practices on test utilization across populations, to ensure safety, efficacy, and utility. Expert, Teacher, Scholar, Advocate Most importantly: Pathologists/Laboratory Directors are leaders first, and utilize their extraordinary professional skills to promote improved healthcare outcomes across the populations they serve. Corollary: Pathologists/Directors have to step forward as leaders within their regional health systems (however integrated or fragmented such systems may be).

22 Ergo Pathologists and the Clinical Laboratory have a central role to play in the Patient Centered Medical Home, the Medical Neighborhood, and the Accountable Care Organization models