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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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
Scientific
Ethical
Payment
Organization
Processes
Information
Implementing The New Model : The Method
Evidence-Based Quality Management
=
xMotivation Capacity
Towards a New Model in GM Care &Quality Management
* 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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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%
Towards a New Model in GM Care &Quality Management
The New Model : Proof of Concept
• proactive chronic disease management
USA : HealthPartners Medical Group - 5 years of Patient Centered Medical Home
QI: +33%Costs: -10%
COST
Diabetes QI
Patients satisfaction
Towards a New Model in GM Care &Quality Management
The New Model : Proof of Concept
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»
Towards a New Model in GM Care &Quality Management
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 New Model in GM Care &Quality Management
Towards a Belgian Vision
KCE report 76B 2008Promotion of Quality In General Medicine ; Status Quo or Quo Vadis?
Towards a Belgian Vision
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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 €
Towards a New Model in GM Care &Quality Management
In God we trust
all others must bring data!
Edwards Deming, the father of quality management
Quality Management needs DATA
Towards a New Model in GM Care &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
Ok for my 390 €/patient .
Q: What about the other 2400 € ?
My RIZIV Profile
What data do we have today for quality management ?
Towards a New Model in GM Care &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 ?
Towards a New Model in GM Care &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 ?
Towards a New Model in GM Care &Quality Management
Let’s get the quality management data from the Diabetes Care Pathways
Diabetes in daily General Medicine Practice
Towards a New Model in GM Care &Quality Management
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?
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
Efficiency
UsabilityUsability (& Adoption) have aBreak-even pattern
Adoption
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
The user can see his compliance level with the clinical decision support rules benchmarked against the his local, regional and national networks .
Towards a New Model in GM Care &Quality Management
What means Decision Support for Quality Management
Towards a New Model in GM Care &Quality Management
Translation from population orientated Quality Indicators to patient based customizable Quality Alerts
What means Decision Support for Quality Management
Extend the EPR with a
user friendly care process manager
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Define the care teams and Multidisciplinary Care Networks with role and identity based mandates
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Generate automatically structured and coded data through predefined templates and terminologies
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Prescribe directly from the alerts and delegate corresponding tasks
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Send the tasks that can be delegated to the coach
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Show the care process status of all members of the team to directly manage the tasks
Towards a New Model in GM Care &Quality Management
How do we get quality management data from the physicians without extra work ?
Generate the notes automatically from the task templates ( structured and coded format exchangeable with the EPR)
How do we get quality management data from the physicians without extra work ?
Towards a New Model in GM Care &Quality Management
Nr1 : With everybody at once will never work .
Why ?
Towards a New Model in GM Care &Quality Management
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 *.
Implementing The New Model : the final challenge = change management
*Peter Drucker
Towards a New Model in GM Care &Quality Management
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
Towards a New Model in GM Care &Quality Management
Implementing The New Model : the final challenge = change management
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
Towards a New Model in GM Care &Quality Management
It is not because things are difficult that we do not dare,
it is because we do not dare that things are difficult.
Seneca
Towards a New Model in GM Care &Quality Management
Towards a New Model in GM Care &Quality Management
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)
Towards a New Model in GM Care &Quality Management