Towards a New Model in GM - Domus Medica · PDF fileTowards a New Model in GM Care &Quality...

Towards a New Model in GM Care &Quality Management

Towards a New Model in GM

Care & Quality Management

05.03.2011Dr S Braga, prof Dr JJ Van Lochem, Dr Ph. Vandenbergh

Consumers

ACCESSIBILITY

QUALITY

CONSIDERATION

FINANCIAL SOCIAL

Providers

Payers

EFFICIENCY

Cost Containment

The Healthcare Challenge

Favorable Business

Environment

InnovativePharma

QualityManagement


the Quality - Cost - Access equation

“We won’t get increased access to care for all without cost containment”

“We won’t get cost containment without fundamental changes in the delivery of care to improve quality”.

“We won’t get value without a greater integration of evidence-based medicine and evidence-based management.”

Stephen M. Shortell, PhD, MPHSchool of Public Health Blue Cross of California , Professor Health Policy and Management, Professor of Organization Behavior

The Foundation for a New Model


Scientific

Ethical

Payment

Organization

Processes

Information

Implementing The New Model : The Method

Evidence-Based Quality Management

=

xMotivation Capacity


* Nick Goodwin, Chuck Kilo, Jennifer Dixon, Josep Argimon, Michel Wensing, Chris Ham, Bert Vrijhoef, Jochen Gensichen, John Tooker, Ed Wagner, Derek

Feeley, Marianne Samuelson, Zbigniew Krol, Anne Frolich, Norbert Donner-Banzhoff, Yann Bourgueil, Barbara Starfield, Sophia Schlette, Tino Martí, Melanie

Lisac, Sophia Chang, Thomas Heil, Frede Olesen, Ain Aaviksoo

Population-Oriented Primary Care (Bellagio Model )

A reference framework for accessible, continuous, comprehensive, population-orientedcare coordinated by the primary care level

Based on :

1. 20 years of experimentation with the Chronic Care Model2. the results* of different approaches and strategies from nine countries : UK, DK, Spain

(Catalonia), USA, D, F, P, NL in 2008

The experience adjusted the focus from single chronic diseases management

of individual patients to whole person approach and population management

The New Model : The Scientific (Public Health) Foundation


1. Shared leadership – policy makers , payers and providers

2. Public trust - transparency of policy makers and providers for quality, efficient care

3. Population-oriented management

4. Integration – primary and secondary care, social services

5. Infrastructure

Knowledge : evidence-based guidelines

Information Technology

6. Payment mix – capitation , incentives

7. Standardized measurement – systematic benchmarking (quality indicators)

8. Structured change management : goals, actions, measurement and evaluation

Population-Oriented Primary Care Model

The New Model : The Scientific (Public Health) Foundation


GERMANY: QuE Physicians Network Nürnberg - 3 Years Pay for Performance

1.Prime for Performance

- sharing the realized economies with respect to the medium cost (AOK Bayern )

40% Patient (Insurance) <> 40 % Physicians <> 20% cover the management costs )

2.Multidisciplinary team

3.Guidelines

4. Professional Management

5. Quality Indicators and patient satisfaction (Benchmarking - Feedback)

QI: 8% -10% better

Cost reduction : 12%

The New Model : Proof of Concept


SWITZERLAND: 10 years of Managed Care

50% of the GPs manage their patients by MC

800.000 patients on MC ( 12%)- GPs Association- Reduced patient own payment - Quality Indicators / Quality Circle

QI : 76 % on target

Cost reduction : 18 - 24%

Revision of the Health Insurance Act in 2010- All insurance must propose a MC plan- Patients are not obliged to register with MC- Non MC patients will pay a TM of 20% instead of 10%



• proactive chronic disease management

USA : HealthPartners Medical Group - 5 years of Patient Centered Medical Home

QI: +33%Costs: -10%

COST

Diabetes QI

Patients satisfaction



14.000 MDs ; 5 mil patients in Medical Homes in USA !

The New Model: The Biggest Surprise : the GPs are ready !

FRANCE - Contracts for improvement of individual practices

12 quality indicators

Q Incentive: 7€/patient (3000 €/GP/year)

Expected case 3000 (2010)

15.000 GP (2010)

What about the profesional leadership?

MG France : No to CAPI !

CSMF : Orderd the boycott => State Council Appeal

L’Ordre : Negative decision=> State Council Appeal

SFMG : «co-management of the process to ensure guarantees for the physicians

=> L’Observatoire de Médecine Générale as an indispensable bussines tool»


1.Resources will be allocated only if we can show the results

- Evaluation/evolution by the profession

or

- Tighter administrative constraints

2.The tasks of the GP can not be covered only by fee for service

3.Large informatisation

Dr B Vercruysse :

La médecine générale est malade, que faire ? Santé conjuguée - octobre 2007


Towards a Belgian Vision

KCE report 76B 2008Promotion of Quality In General Medicine ; Status Quo or Quo Vadis?

Towards a Belgian Vision


Federaal Kenniscentrum voor de Gezondheidszorg - Centre fédéral d’expertise des soins de santé

Quality Management Governance • Scientific• Ethical• Professionalized • Paid

Governance for Trust

The physicians own and manage their data

Governance for Standards

Define the information , knowledge and process model

Governance for Knowledge

Knowledge Management Tool with expert support to transform the clinical guidelines in usable software

Governance for Data

Platform for integration , process coordination , analytics

Data ManagementServices

Implementing the New Model : Quality Management - Organizational Foundation


Patient StatusData

Data

KQI

Patient StatusData

Data

KQI

Patient StatusData

Data

KQI

CDS Operational Process Management

Benchmarking

Strategic Process Management

Process Reenginering

Care flow execution

Activity 1 Activity 2 Activity nD

Alerts

Knowledge Based Medical Management with

Decision Support – Benchmarking - Process Reengineering

Clinical Guideline

CDS :clinical decision support

Agreed Care Plan

Quality /Safety /Efficiency

Indicators

Implementing the New Model : Quality Management - Functional Foundation


Patient

GP

Nurse

Hospital

Payer

P4Q Primes

global

QI Data

anonyme

Care Management Institute

Gouvernance Clinical ExpertsPublic Health Experts Coaches / Managers

Implementing the New Model : Quality Management Business Model

Clinical Process Management Platform

Patient Care Plan

Policies

Policies => Care Process Models , QI

QI Data

P4Q Primes

individual


http://fr.fotolia.com/id/10438765




Health care

model conceptInstrument Operative means Data-processing tools

Quality

Improvement

Expectable

Economies

Actual

situation

Solo doctor Patient Record 1. Local EPR -0,3%1

Level 1

Patient

centered

Care

Providers network

Shared EHR

Patients portal for

health

Shared secretary

1. Shared EHR web app + EPR

3. Semantic interoperability: EPR-EHR

4. Shared Practice Management App

GENERATION 3 Systems

7 % 2

Level 2

Quality

management

Efficiency

Management

Disease Management

Quality Indicators

Benchmarking (feed-

back)

Capitation

Pay for Performance

Care plans - Care team

Task management

Drugs alerts

Guidelines: alerts

reminders

1. Knowledge Management System

2. Process Management System

care plans ,actors, roles contexts,

actions/tasks, events, rules, QI

3. Decision Support System

4. Analytic tools

GENERATION 4 PLATFORM

8 %

30 %

10 %

20 %3,4,5

Integrated system for care

management

Prevention and Disease Management

Quality and Safety Management

Guideline based care

coordination

Quality indicators

Quality based incentives

Predictive Modeling

Process Re-engineering25-30% 25%

6

1.Implementation du projet RIPAM (Ardeèhe) : une « 13éme heure » de travail de plus par jour pour tenir le DMP2.Bilan 2004 de la Mutuelle Knappschaft en Allemagne après introduction d’un dossier informatique partagé « Web » pour tous les médecins 3.Bilan 2006 Suisse : 10 ans des systèmes de Managed Care ; Observatoire Suisse de la Santé 2006 ; Bilan 2010 Réseau Genève , Zurich Bern ; Bilan 2009 QuE Nürnberg4.Infoway Canada 2005 - Coût évitable des effets indésirables des médicaments par prescription informatisée avec support décisionnel5.Etude prospective , randomisé à grande échelle «Improve Compliance with Clinical Guidelines.. » Jonathan C. Javitt et all ; AJMC 2005 6.Bilans Kaiser Permanente vs moyenne nationale et californienne

The Possible Deal for the Patient and the Payer


PRODUCTIVITY = free time ( ! 50.000 MDs shortage in 10 Years in Germany)

Daily work support => 1 hour/day time gain

+Task delegation => +1 hour /day time gain (capitation !)

INCOME

+ 10-15% Income through Pay for Quality

PRESTIGE SCIENTIFIC SOCIAL


The Possible Deal for Providers

Healthcare Management Institute

Guidelines Analysts Mangers CoachsStandards

Insurance

MD Primary Care

Financial balanceTotal costs of «management» = +/- 80€ feasible economies = +/- 300€

EMR 1

provider

EMR 2

provider

+ 300 € /insured

- 80 €/insured

MD Specialist

HIT Service Platform

Integration / Continuity of Care / Disease Management

GP managed PHR

11 €

Implementing the New Model = Financial Model

Interoperability Incentives

2 €

3 €

Performance Incentives

Performance Incentives 20 €

for primary care nurse 30 €50 €

12 €

2 €


In God we trust

all others must bring data!

Edwards Deming, the father of quality management

Quality Management needs DATA


*Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure A Meta-analysis ; Christopher O. Phillips, MD, MPH, JAMA. 2004

Ok for my 390 €/patient .

Q: What about the other 2400 € ?

My RIZIV Profile

What data do we have today for quality management ?


Q: how am I performing on :

- Heart Failure => 100 mil € potential economies Belgium*

- HBP and Diabetes => 120 mil € potential economies Belgium**

- Avoidable ADE => 700 mil € potential economies Belgium***

What data do we have today for quality management ?


*Comprehensive Discharge Planning With Postdischarge Support for Older Patients With Congestive Heart Failure A Meta-analysis ; Christopher O. Phillips, MD, MPH, JAMA. 2004**Excess Morbidity and Cost of Failure to Achieve Targets for Blood Pressure Control in Europe LENNART HANSSON et all , BLOOD PRESSURE 2002**Improving Chronic Disease Management: A Compelling Business Case for Diabetes; British Columbia Ministries of Health and Novartis Pharmaceuticals Canada, 2002**German Diabetes Management Programs Improve Quality Of Care And Curb Costs ; Stephanie Stock,et all ; Health Affaires December 2010*** Infoway Canada - Projected costs and benefits ; Booz Allan Hamilton 2005

Let’s get some quality management data from Mutualities /RIZIV ?


Let’s get the quality management data from the Diabetes Care Pathways

Diabetes in daily General Medicine Practice


The Diabetes Care Pathways are concerning

-only a minority of the diabetic population

-only a minority of the daily work of a GP

• 3 contexts out of 16

• 12 activity types out of 62

• 4 parameters out of 18

STUDY:

Improving quality in general practice based on registration of data for Type 2 diabetes and Hypertension

« 40% of the physicians who registered for the electronic method based on their EMR finally did not send the data. »

Étude du Service d’épidémiologie de l’Institut Scientifique de la Santé PubliqueVandenberghe H., Bastiaens H., Jonckheer P., Orban T., Declercq E.,Lafontaine M.-F.,Van Casteren V. 2003, Bruxelles

Let’s get some quality management data from motivated physicians?


The systematic use of a collaborative EHR generated 1 hour more work per day: "the 13th hour" as general practitioners use to call it.*

In the context of the general medicine, that represents a loss of productivity of 7%

= 7.000 – 10.000 € losses supported by the GP

Lets ask the GPs to produce the quality management data ?

*Réseau d’information patient de l’Ardèche méridionale (RIPAM) France


26

“ If you do not have all information for all the patients , all the time

you are wasting your money ”

George Halvorson, CEO,Kaiser Permanente


How much data do we need in fact for effective quality management ?

10 % lower insurance primes

25% lower medical costs

Kaiser vs. California Control Group (2007)

Impact of Kaiser competitive pressure on the primes in California vs national average (2000)

Why should we believe Kaiser in quality management matters ?

• Cut Heart attacks by 24 % in 10 years

• Cut fractures in osteoporotic patients by 37%

• Cut hospitalization in patients with co-morbidity by 70 %

Latest news from Kaiser Permanente


9 million members, 14.600 physicians

The physicians

must enter all the data

of all the patients

all the time !!!

How do we get to all information for all the patients , all the time


What is a physicians asking for entering all information, all the time?

“Extremely Important” for the Physicians

1 Speed of data entry 97%

2 Flexibility 80%

3 Interoperability 58%

4 Advanced Decision Support 53%

State of the EHR –AHIMA Report 2004


Efficiency

UsabilityUsability (& Adoption) have aBreak-even pattern

Adoption


What do we need for Speed +Flexibility + Interoperability + Decision support ?

Generation 4• Process management• Knowledge management

All studies and meta-analysis concluded that :

Electronic Patient Records

are not enough for quality improvement

>> We need clinical decision support .

1.EMR Sophistication Correlates to Hospital Quality Data, Comparing EMR Adoption to Care Outcomes, HIMSS 2007 2.Electronic Medical Records and Diabetes Quality of Care: Results From a Sample of Family Medicine Practices

Jesse C. Crosson, PhD ANNALS OF FAMILY MEDICINE MAY/JUNE 2007 3.Electronic Health Record Use and the Quality of Ambulatory Care in the United States ; Jeffrey A. Linder ARCH INTERN MED JULY 20074. The Value of Information Technology-Enabled Diabetes Management; Davis Bu,Center for Information Technology Leadership. 2007


Why quality improvement comes only with generation 4 Systems?

What means Decision Support for Quality Management

The physician can see his diabetic patients and their active alerts ranked by risk or overdue deadline


The user can see his compliance level with the clinical decision support rules benchmarked against the his local, regional and national networks .




Translation from population orientated Quality Indicators to patient based customizable Quality Alerts


Extend the EPR with a

user friendly care process manager


How do we get quality management data from the physicians without extra work ?

Give one screen access to patient data and processes (“care plans”) : tasks , alerts and deadlines

patient data care plan Alerts

Deadlines

Executable Tasks with automatic coded data generation



Define the care teams and Multidisciplinary Care Networks with role and identity based mandates



Generate automatically structured and coded data through predefined templates and terminologies



Prescribe directly from the alerts and delegate corresponding tasks



Send the tasks that can be delegated to the coach



Show the care process status of all members of the team to directly manage the tasks



Generate the notes automatically from the task templates ( structured and coded format exchangeable with the EPR)



Nr1 : With everybody at once will never work .

Why ?


Implementing The New Model : the final challenge = change management

**Canted et al., JAMA 1999

Why Don’t Physicians Follow Clinical Practice Guidelines - A Framework for Improvement**

CULTURE

Nr 2 : Culture eats strategy for breakfast *.


*Peter Drucker


Use the “microsystem” method (Barach et al., QSHC 2006) (Kaiser)

1. A sample of all structures types , all provider types and all processes types typically encountered in the “big system”

2. Synchrony of all chagement types

3. Use practicing providers ,pay them for the experimenting part of their activity (applied research)

4. Show to the others

Nr 3 : “People change less because they are givenanalysis that shifts their thinking than because they areshown a truth that influences their feelings.”*

The Heart of Change , John P. Kotter H A R V A R D B U S I N E S S SC H O OL P R E S S 2006



Framework for design and evaluation of complex interventions to improve health *

2010

2011-2012

2 years

20 GP

2013

1 year

100 GP

1 year

200 GP

2014

Michelle Campbell ; BMJ 321,2000

Evidence based change management for quantity interventions


It is not because things are difficult that we do not dare,

it is because we do not dare that things are difficult.

Seneca



Further Documentation

www.qualityforcare.com

NHS Reform 2011- 2013 : “Available to all, free, based on need, not the ability to pay”

Quality Management is the pillar of the reform

• Quality evaluation will be extended to all providers of NHS

• Information about the quality of care will be publicly available

• NICE to produce 150 standard guidelines and related QI

• Contractual obligations for accuracy and timeliness of quality data.

• Agreed technical and data standards to promote compatibility.

• Patients will be able to rate services according to the quality

• Patients will have access to their record

Funding 1. a weighted capitation model adjusted for quality 2. budgets will be given to “GP consortia » ( 80% of the total budget)


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