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

January 29, 2009

The Medical Home – Position Paper on Innovation

Filed under: Innovation Adoption,Medical Home — Tags: , , — David Kauff @ 8:53 am

Like many of you,  I am working to understand and adopt the priniples of the Medical Home into my practice and  how to leverage technology to make really work.   Reviewing the currnet liturature in the Medical Home can be a dizzying undertaking.  The Medical Home is defined as a Model, a Concept, a Movement, an Innovation and even a software package.  The term itself is under scrutiny, what is a Home?  what is an Advanced Home?  Depsite the ambiguity of name, there is no ambiguity of purpose.  I want to share what I have found to be a clear articulation of the guiding principles and benefits of the Medical Home both from a clinical and Informatics perspetive.  The paper is from the Deloitte Center for Health Solutions in Washington D. C.  I hope this serves as a springboard for both discussion and reference as we move foward with this work.  It is well worth the time to read.  Here is the link:
Medical Home Article

January 26, 2009

Capturing Race and Ethnicity data

Filed under: data warehouse,Electronic Chart,Quality / Affordability — Matt Handley @ 10:46 am

At Group Health, we have gone back and forth about the capture of data on race and ethnicity.  There was a time when our board was reluctant to capture these data, worried that collecting the data implied that we were not taking care of people equally.  While this had noble intent, the upshot has been that we don’t know about important disparities in care that are likely to exist – which makes it harder to address them.

The GHP board recently had a daylong learning session about diversity.  A great day, with many lessons for all of us.  One fascinating presentation showed how the use of race and ethnicity data helped improve patient satisfaction in KP Northern California.  KP collects data on race and ethnicity, and provides clinicians with an analysis of their patient satisfaction surveys broken down by different patient characteristics, including age, gender, prior visit with the provider and race/ethnicity.  It changes everything – instead of a global rating, it identifies discrete populations that may be more challenging for a clinician.  It also shows that differences in performance may not be related to skills, but instead to how many new patients a provider sees (we consistently score higher with patients we already know, so clinicians seeing more new patients will have lower scores than clinicians seeing their own patients, even though both clinicians score equally well when they see a new patient or a patient they already know).

We have had several failed efforts to collect data on race and ethnicity, and do collect it now in the health profile (the online health risk assessment tool on MyGroupHealth).  We are set to tackle collection of race/ethnicity for all of the members enrolled in Group Health plans – we will be learning from other organizations and from our past efforts.  We hope to bring forward work to be “pulled” by the Executive Leadership Team for the second quarter of 2009.

Would love your thoughts and ideas about both how we might collect the data and how we might use it to improve the quality and value of the care we deliver.

January 13, 2009

The Guru of Clinical Variation visits Group Health

Filed under: Clinical variation,Content of care — Tags: — Matt Handley @ 5:24 pm

Jack Wennberg, the “guru” of small area variation, spent a few days at Group health recently.  He worked with the effort that GHC promoted (and the state sponsored) to promote shared decision making in our wider community, and help us advance the work taht is being sponsored by the Content of Care team in many specialties.

Dr Wennberg is a remarkable doctor and researcher.  He started with some powerfully naive questions in the 70s – why was it that one town, on the east side of a river, had a tonsillectomy rate of 20%, and the town on the other side had an 80% rate?  Were the patients that different?  Years of research have confirmed that while we think of medicine as a profession that is objective and science based, the research that Dr Wennberg and his group have pursued has shown convincingly that it is driven more by local physician culture and “supply” (of doctors, hospital beds, scanners, etc), than it is by clinical circumstance.

A group of clinical opinion leaders from our specialty group had dinner and a conversation with him last week, in advance of our work to systematically introduce the use of clinical decision aids into our practice for a few defined conditions in clinical areas defined as “preference sensitive” care – areas where patient preferences regarding the different outcomes and interventions should drive decision making.  The areas include total hip and knee replacement, management of BPH, management of uterine bleeding and fibroids,  and back surgery.

Some tidbits to check out:

1.  the first study of shared decision making – done at GHC, in men with BPH (published in 1995)

medical care sdm bph study

2.  The Ottawa decision aid for shared decision making (and interactive PDF, and a print version)

ottawa decision aid print

ottawa decision aid interactive

3.  The latest installment of the Dartmouth Atlas, chronicaling the variation in care in the US in the care of patients with chronic illness

2008 dartmouth atlas chronic care

An interesting road ahead, with our specialty group doing what no group in the world has done before – a system wide implementation of shared decision making tools, supported by clinicians.  Here’s to better decision quality, and variation driven only by patient preference and clinical circumstances!

January 7, 2009

Practice Management Update

Filed under: Practice management — John Kaschko @ 11:52 am

One of the major Informatics projects this year is implementation of “Practice Management.”  Practice Management isn’t one specific application, it’s really the project name for implementing about 13 new applications, most of which are Epic applications.  This project will replace the LastWord application for appointing, registration and billing so that all of our business and clinical information systems will be in Epic.  For Central campus, the “Inpatient” facilities will move from paper to Epic (documentation, order entry).  Adding these new applications will also enhance services on MyGroupHealth including the ability to view and pay bills on line.  Another required application in order to replace Lastword is a cash management system.  This system will allow electronic patient signatures. The “go live” date is October 3, 2009.

The multiple application names and what they do can get confusing and the impact of GHC staff will vary.  A useful  way to think about the Practice Management project is to group the applications and work into 3 areas: Appointing, Inpatient and Billing (click on the link below to show a diagram of the existing applications we use (in the gray boxes) and the new applications (white boxes) for these 3 areas).

practice-management

While each of these areas involves a significant amount of work to build and test the applications, the impact on staff will vary by area.

For our business office staff, this will be a change akin to when clinical staff went live with Epic Ambulatory (aka REALLY big and REALLY stressful).  There will be a learning curve and getting used to the new system, but Epic’s products are much better than Lastword and staff will quickly be much happier with this improved functionality.  To the extent we build/test/fix the bugs ahead of time, this will make their transition much easier.  However, in October, I would encourage you to remember your past and what it was like to “go live”…,.. if someone seems short or cranky, be tolerant and tell them “…I remember what it was like, hang in there, you’ll be much happier with Epic.”  Lattes optional but likely appreciated…………

With our Inpatient facilities, the impact will be on both ends of the spectrum.  For providers who already use Epic, while there is new functionality to learn, it’s really more about how things are displayed and current Epic users will make the transition to Inpatient Epic relatively easily.  For our nursing staff/support staff/business office staff….this is their Epic implementation.  Much more change going from paper to Epic.  They will need and get much more training/support than provider staff….and our providers can help both from an encouragement standpoint and as “superusers.”

For our outpatient clinics, clinical staff will be impacted very little. The Schedule screens will look different (and better with more information), but there will be little change in day to day work.  Clinical staff will have the ability to quickly schedule appointments when talking with a patient rather than transferring the call through “Quick Appointment” functionality.  With these appointments, the necessary billing/guarantor information is captured when the patient registers. While we will experience little impact and improved functionality, our business office staff will be going through their Epic implementation….

The one downside of the project is that with all these applications and need to integrate them together,  it requires a great majority of our technical staff.  As a result, we are “short” when it comes to having staff to be able to make changes in the existing Epic applications.  There are lots of great ideas for improvements and new functionality is available, but resource constraints with Practice Management have significantly impacted our ability to take on “new work.”  Decisions on projects that are taken on are made jointly by the  delivery system leadership team and Informatics leadership so we leverage the limited resources available to the greatest extent possible.

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