It’s Not About The Box Improving Care at Group Health with People, Process and Technology

December 17, 2008

High End Imaging – Roll Out Slideshow

Filed under: Uncategorized — Matt Handley @ 7:42 pm

I was scheduled to present the content for improving the value of high end imaging to the primary care chiefs today – but in typical Seattle fashion, the weatherman (who can only lose a job by failing to predict snow when it does snow) – missed and fooled us all.  Threat of a great storm led Claire Trescott and Michael Erikson to cancel so that the clinic leaders could be out supporting their clinics through the chaos of a snow day – very reasonably.

So – I have tried to narrate the slide show as I would have done it if we were all together.  Not the same as being together for a conversation, but hope that it is helpful.  Check the link below for a few minutes – there is sound – so make sure that you are able to hear (might need to watch from home).  It is a BIG file – might take  a minute to load.  Glad to answer any questions.

improving the value of high end imaging

December 10, 2008

“Practice Management” project – More than just business systems

Filed under: Uncategorized — Matt Handley @ 1:14 pm

The major IT project underway at Group Health right now is generally referred to as “Practice Management”, and has as its largest component the installation/implementation of  Epic’s components for appointing, registration and billing (Epic refers to them as Cadence, Prelude and Resolute, respectively).  Those go a long way to replacing Last Word, but we will also need to put in place many other systems to be able to retire that dinosaur (and lower our operating costs by more than $750,000 a year).  The “business” side of the project is huge, and in addition to Epic includes a point of sale/cash managment system and several important back end business applications.

What is often lost is in the discussions about “Practice Management” is that we will also be implementing Epic’s InPatient functionality and enhancements to MyGroupHealth.  We don’t have a large hospital, but we do have inpatient services – L&D, EOS, and infusions centers, to name a few.  While there are not too many clinicians who will use these new features, they will be a real win for our clinical group, and many of them will eventually be available in our outpatient clinical tool.

A comprehensive list of the inpaient functionality that is in scope for the project, and the clinical areas where they will be implemented can be downloaded here.   Epic InPatient Scope

December 5, 2008

Smartphrase of the week

Filed under: After Visit Summary,Smartphrases — Tags: — Matt Handley @ 2:01 pm

The informatics team has been trying to figure out a way to collect and share smartphrases (see prior blog entry here).  There are some changes that we will explore for future releases of Epic, but in the meantime we are going to try a simple way of collect and share smartphrases – it isn’t very exciting, but it is a start.

We are going to solicit favorite phrases through the CIS newsletter email and collect them here – we will come up with some small inducement (Starbucks cards, etc) to see if we can get some coming in.

I will start with my favorite for responding to patients’ questions about supplements – it follows.  My naming convention uses “PM” for patient messages – anything that goes directly to patients (in patient instructions for the AVS or in secure messaging).

Smartphrase “PMSUPPLEMENTS” below…..

Thanks for asking – I think that a healthy skepticism about any advertisement is a good idea – and that is especially the case with nutriceuticals like ***.

This may all be information that you already have/know, but some background about supplements:
1.  There are no standards for manufacture for any supplements – and independent testing of products have shown that they commonly do not have the advertised ingredients, and have not uncommonly had pesticides of other contaminates (best source is consumerlab.com).  For instance, a recent study of Ayurvedic medicines (traditional Indian remedies) found that 20% of products manufactured in the US contained dangerous levels of heavy metals.
2.  There is almost no regulation about what they can claim – they do not need anything more than a testimonial to claim effectiveness.  Given that in carefully controlled studies of problems like fatigue up to 40% of patients taking a placebo report improvement, it is clearly not enough to have someone take a product and feel better to be sure that there is any benefit to the supplement.
3.  There is no system for collecting safety data about these products.  While several are clearly harmful (like ephedra), it has taken many years to get them removed from the market.
4.  To the extent that they work, they are drugs (defined as substances that are ingested to change the structure or function of the body).  They just come in unregulated doses without clear safety data.

The Future of Primary Care

Filed under: Medical Home,Optimization,Quality / Affordability — David Kauff @ 10:28 am

I feel a deep personal obligation to help solve this problem.  As a Primary Care Internist, I have both a very personal stake in how we promote and improve our specialty, and more than ever, how do we here at Group Health insure that we attract and retain only the best of the best.  It is projected that in 2025, there will be a shortage of 46,000 primary care physicians in the county.  Far more than initially thought.  The article here is an excellent articulation of the crisis and puts forward solutions.  As you read it, you will see, as I have, that the Medical Home is a common theme, from the evidence based, team approach, to value streams that reward quality of care in lieu of productivity pressures or additional time in the clinic. Here is the article, it is my intent that this will start a good conversation on how we both innovate and preserve a fundimental part of our care delivery system.

Worsening Primary Care Shortage Predicted

 
Experts recommend work redesign and payment reforms
HealthDay News — America’s looming shortage of generalist physicians is destined to reach crisis proportions by 2025 if nothing is done, experts are warning.

In a string of reports and commentaries, leaders in primary care and health policy have begun fleshing out the problem and offering up potential fixes.

“There’s no single step that will solve the problem, but I think it’s going to require multiple approaches,” said Dr. Jack Colwill, professor emeritus of family and community medicine at the University of Missouri School of Medicine in Columbia.

Many policy experts believe that fixing primary care would also go a long way toward mending a broken health system.

“At a time when the new president and Congress are looking for ways to improve quality and save money, what we’re trying to get across is that primary care is certainly a big part of that solution,” said Bob Doherty, the ACP’s senior vice president of governmental affairs and public policy.

Indeed, the World Health Organization recently called for a renewed emphasis on primary care to ensure equitable access, better outcomes and healthier communities around the globe. “Countries need to demonstrate their ability to transform their health systems in line with changing challenges as well as to rising popular expectations,” the report noted.

In the U.S., the Association of American Medical Colleges (AAMC) is projecting a shortage of 46,000 primary care physicians by 2025. Primary care will account for 37 percent of the overall physician shortage. The AAMC’s estimate is consistent with projections by Colwill and his research team, who anticipate a shortage of 44,000 generalists by 2025.

Many parts of the country are already feeling the pinch of an inadequate primary care workforce. It would take an additional 8,000 primary care physicians to fill demand for services in areas currently designated by the federal government as underserved, the AAMC observed.

The New England Journal of Medicine’s Nov. 13 issue spotlighted primary care with a series of articles and a roundtable discussion on possible solutions.

Dr. Thomas H. Lee, network president for Partners HealthCare System in Boston, explained that boosting pay is not a panacea because many organizations have found that primary care doctors respond by seeing fewer patients.

“These physicians, it turns out, place a higher priority on trying to do a good job and having a sane life than on making a higher income,” he wrote. “The message they’re sending is that more money will not be enough to revitalize primary care.”

A lot of residents reject primary care because they’re afraid of the enormity of the task, observed Dr. Katherine Treadway, an assistant professor of medicine at Harvard Medical School.

Dr. Thomas Bodenheimer, professor at the Center for Excellence in Primary at the University of California, San Francisco, proposes relieving primary care physicians of many patient care burdens by implementing a team-based approach and restructuring the reimbursement system accordingly.

As “team leaders,” physicians would handle no more than 10 patient visits a day. The rest of their day would be spent handling telephone and electronic encounters, ordering medication changes, and consulting with team members, including health coaches and panel managers.

Having others order preventive screenings and teach patients about making lifestyle changes would go a long way toward relieving the burden on the typical 15-minute patient encounter, he said.

A team approach has become universal for primary care in the United Kingdom, noted Dr. Martin Roland, director of the National Primary Care Research and Development Centre at the University of Manchester. However, a recent study reveals a concern that the increasing use of nurses in providing protocol-driven care for chronic disease may result in physicians becoming “deskilled.”

Dr. Allan H. Goroll, professor of medicine at Harvard Medical School and chair of the Massachusetts Coalition for Primary Care Reform, and his colleagues propose a new primary care payment model that would replace volume-based reimbursement with comprehensive payment for comprehensive care.

Applying evidence-based, coordinated care would reduce wasteful spending, freeing up money to fund the new payment model, which would result in a primary care pay hike of as much as 40 percent, Goroll estimated.

Having better patient-level information on quality and outcomes and using information technology to facilitate that care would be part of the solution, envisioned Dr. Barbara Starfield, professor of health policy and management at Johns Hopkins University’s Bloomberg School of Public Health in Baltimore.

“The message we’re trying to send to policymakers and to our own members is that studies show that primary care really is the best value in the U.S. healthcare system; that if you pay primary care physicians fairly for their services, you will get better access, better outcomes and overall lower cost of care,” ACP’s Doherty said.

December 3, 2008

A conversation about secure messaging

Filed under: MyGroupHealth,Secure Messaging — Tags: , — Matt Handley @ 8:28 pm

Seth Scott, a doc at Olympia relatively new to GHP, took the time to send me a very thoughtful message about the challenges of using secure messaging – he has graciously agreed to have me share our conversation with you on the blog:
_____________________________________________
From:     Scott, Seth
Sent:    Wednesday, December 03, 2008 9:29 AM
To:    Handley, Matthew R.
Subject:    On secure messaging

Matt,

This is a philosophical sort of point, something I’ve been mulling over, in varying forms, for longer than just since the last associate program meeting:  the more I re-examine it, the more I realize what a mixed blessing secure messaging is.

I agree that in some instances, and moreover with certain personality types, secure messaging can reduce work and improve efficiency and satisfaction both, while improving quality of care.

That said, there are instances in which these resoundingly are not the outcomes, and these can be somewhat hard to predict, even for the so-called internet savvy.  I can’t speak in terms of numbers of patients, but for one population that I see (often a mixture of anxious/type A/technophile, although not always), secure messaging feels like treading water to me.  Very thick and tiring water, at best.  There are also people who just don’t know the medium and who are prone to greatly misunderstanding the tone of a message.  Exchanges occur, and despite my fairly reasonable sense of netiquette, the exchanges can at times create even more work and don’t “prevent” another encounter (they spawn more encounters).

Exchanges often go badly when the initial message is charged or otherwise “on the offensive,” ie, “why is it that group health won’t let me have my colonoscopy/DEXA scan/fifty irrational naturopath-recommended tests?”  This is only the grossest example, though, with which we are all familiar.  Not all are so easy to forsee.

Provider understanding of how to best close a thread (with appropriate etiquette), or even understanding that a thread ought to be closed, is highly variable.

I am not trying to fly in the face of your overall enthusiasm for online services, but I am just trying to add my opinion in temperance.  I think that my opinion counts with some weight, too — I am well in the front of the thirty-something technophilic generation of MDs.  I was in college when the web was born, and I type faster than anyone else in my clinic that I’ve witnessed, including clerical staff, and I treasure EPIC as a tool — I view myself as an outlier on the computer-comfortable end of the continuum.  I think that secure messaging is a great and useful tool.  But I believe it is a very specifically useful tool, and the limitations can take one some time to fully learn, even for me (having had my first internet-based misunderstandings in the late 80’s, on campus-run bulletin boards — in one sense, I’m a twenty year veteran of internet-based misunderstandings!)

I think it would be valuable for new-to-GHC providers to hear that note of caution, more briefly and well put than I have it here.  Also, formal discussion and consensus, perhaps, on the “times to opt out” of a message exchange might help some providers, both new and established.

– Seth Scott MD, OMC

and my reply….

Seth
I really appreciate you taking the time to reflect on the use of secure messaging – it is timely.  I pretty much agree with you on most all of these points. I find that many docs use secure messaging in a way that provides great service, but does not improve efficiency.  This really came out in the Rapid Process Improvement Workshop about virtual care. We have not done a good job of defining best practice, and while some use it to great effect, that is not reliably the case.  WE do know that it helps improve satisfaction with both the doc and GHC pretty reliably (but obviously with limitations).  One of the reasons that this evolution has been messy is because we were first, but it is now obviously time to do a more consistently better job.

The RPIW has worked to set some standards for use of both secure messaging and telephone visits – they are now testing their recommendation at a few clinics to make sure that they are sound – and that should help considerably.

The start of a conversation.  Would you be comfortable with my sharing our conversation on the Quality and Informatics blog?

Matt

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