envisioning integrated communication across the primary care and diagnostic service interface...

Envisioning Integrated Communication Across the Primary Care and Diagnostic Service Interface American Board of Radiology Foundation Summit 2010 Kevin Grumbach, MD Department of Family and Community Medicine University of California, San Francisco

Copyright 2010 by Project HOPE, all rights reserved. David C. Levin, Vijay M. Rao, and Laurence Parker, Physician Orders Contribute To High-Tech Imaging Slowdown, Health Affairs, Vol 29, Issue 1, 189-195 CT Scans per 1,000 Medicare Beneficiaries

Copyright 2010 by Project HOPE, all rights reserved. David C. Levin, Vijay M. Rao, and Laurence Parker, Physician Orders Contribute To High-Tech Imaging Slowdown, Health Affairs, Vol 29, Issue 1, 189-195 MRI Scans per 1,000 Medicare Beneficiaries

Too Rad? Bruce Steinwald, GAO Health Care Director: "Advanced imaging is the bellwether for the excesses of fee-for-service medical care.* Radiation dose exposure *Iglehart JK. Health insurers and medical-imaging policya work in progress. N Engl J Med. 2009;360.

Primary Care Family Medicine Source: Robert Graham Center

After-Dinner Speech Etiquette, Or Getting Ones Own Primary Care Medical Home in Order PCPs and other non-radiologists order most imaging studies RAIs notwithstanding Growth of non-radiologist furnishing and self-referral of imaging studies Substantial number of inappropriate referrals for imaging by PCPs and others 26% in one recent study (Lehnert & Bree, 2010)

But at least family doctors know how to communicate with patients well A study of 264 visits to family physicians using audiotapes Patients making an initial statement of their problem were interrupted by the physician after an average of 23 seconds [Marvel et al. JAMA 1999;281:283In 25% of visits the physician never asked the patient for his/her concerns at all [Marvel et al. JAMA 1999;281:283]

Integrated Care The Imperative for Better Communication and Well-Coordinated Care: The Concept of Integrated Care Ann Beal, Aetna Foundation: Integrated health care starts with good primary care and refers to the delivery of comprehensive health care services that are well coordinated with good communication among providers; includes informed and involved patients; and leads to high-quality, cost- effective care. At the center of integrated health care delivery is a high-performing primary care provider who can serve as a medical home for patients.

Integrated Care Systems-level property Functional definition, not structural Foundation of primary care to integrate and coordinate care Communication between clinical team and patients Patient-centered: informed, engaged and activated patients Communication between clinical teams Coordination of services

Foundation of Primary Care is Essential for Integrated Care Abundant research evidence indicates that health systems and regions with a strong foundation of primary care have: Better population health outcomes Better quality of care More preventive care Lower costs More equitable care and mitigation of health disparities

But the Primary Care Foundation in the US is Crumbling Plummeting numbers of new physicians entering primary care and burnout among PCPs Growing problems of access to primary care and medical homelessness Dysfunctional systems that are not delivering the goods in primary care

Communication Problems: Clinician-Patient Asking patients to repeat back what the physician told them, half get it wrong. (Schillinger et al. Arch Intern Med 2003;163:83) Asking patients: Describe how you take this medication -- 50% dont understand and take it differently than prescribed (Schillinger et al. Medication miscommunication, in Advances in Patient Safety,AHRQ, 2005) 50% of patients leave the physician office visit without understanding what the physician said (Roter and Hall. Ann Rev Public Health 1989;10:163)

13 Patient Engagement in Care: Adults with a Chronic Condition AUSCANFRGERNETHNZUKUS Regular doctor always tells you about treatment options and involves you in decisions* (%) 5856435663625153 Your clinician gives you a written plan to manage care at home (%) 4247343135433566 Data collection: Harris Interactive, Inc. Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults. * Among those with regular doctor or place of care.

Practice Routinely Sends Patients Reminders for Preventive or Follow-Up Care Percent 97 89 80 60 51 47 33 32 31 15 Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Additional Communication Issues: Literacy, English Fluency

Problems in Communication and Coordination: Clinician-Clinician

Satisfaction With Information Content and Timeliness in PCP-Specialist Referrals Ghandi TK et al. J Gen Intern Med. 2000 September; 15(9): 626631.

Coordination Problems with Medical Tests or Records in Past Two Years Percent AUSCANFRGERNETHNZUKUS Test results/records not available at time of appointment 1619151211171524 Duplicate tests: doctors ordered test that had already been done 12111018410720 Either/both coordination problems 2325222614212034 Data collection: Harris Interactive, Inc. Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

Coordination Problems with Medical Tests or Records, by Number of Doctors Seen Data collection: Harris Interactive, Inc. Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

PCPs Using Electronic Patient Medical Records in Their Practice, 2006 and 2009 Percent Source: 2006, 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

Models to Improve Communication and Coordination of Referral Services at the PCP-Specialty Service Interface Massachusetts General Hospital model Computer order entry with decision support San Francisco General Hospital model Computer order entry with iterative decision support

Screenshot of the DS feedback displayed after submitting a request for MR imaging of the lumbar spine with symptom of back pain improved with exercise and abnormal result at previous examination of abnormal x-ray DJD. Sistrom C L et al. Radiology 2009;251:147-155 2009 by Radiological Society of North America

Outpatient CT examination volumes Sistrom C L et al. Radiology 2009;251:147-155 2009 by Radiological Society of North America Number of CT examinations ordered through computer order entry.

San Francisco General Hospital

Reengineering Specialty Referrals at SFGH EHR-embedded eReferral system Home grown product developed by SFGH- UCSF gastroenterologist, Hal Yee, MD, expanded by Alice Chen, MD, Gen Int Med Chen AH, Kushel, Yee, Grumbach. Health Affairs 2010 May;29(5):969-71.

Description of eReferral ____________________________ HIPAA compliant web-based referral system Linked to EMR, with auto- population of relevant EMR data Free text referral questions Mandatory use for enrolled specialty clinics and certain imaging studies

Description of eReferral ____________________________ Individualized review and response by specialist Specialists can: Redirect referral if inappropriate for clinic or other options available Request clarification of question or additional work-up prior to specialty appointment Provide information for PCP management of condition, with or without an appointment Overbook appointment if clinically warranted Ability for iterative communication between referring and reviewing clinicians

Average Volume (Ref errals/Mont) % Scheduled Initially (Next Available) % Scheduled Initially (Overbooked) % Scheduled After Additional Review % Never Scheduled CT 310791534 MRI 245473877 eReferral Imaging Scheduling Outcomes

eReferral start

eReferral Evaluation: Specialists ____________________________

eReferral Evaluation: PCPs ____________________________ Overall, how has eReferral changed clinical care for your patients? Primary Care Provider Survey 81% response rate (298 of 368)

Ingredients in Success of eReferral at SFGH Mixed payment model (Medicaid, Medicare FFS + block funding from City for uninsured) Capacity constrained system Network-wide EHR Culture of collaboration, multispecialty medical group Academic physicians

Case for Translational Research and Implementation Science (T2, T3, ) Discovery far outpacing rate of implementation Need for scaling up and diffusion of innovations of proven benefit

Bringing the Patient Into the Communication & Coordination Loop

Stereotactic (Mammographically Guided) Breast Biopsy What is Stereotactic (Mammographically Guided) Breast Biopsy? What are some common uses of the procedure? How should I prepare? What does the equipment look like? How does the procedure work? How is the procedure performed? What will I experience during and after the procedure? Who interprets the results and how do I get them? What are the benefits vs. risks? What are the limitations of Stereotactic Breast Biopsy?

Mamografa En qu consiste una mamografa Algunos de los usos comunes del procedimiento Forma en que debo prepararme Forma en que se ve el equipo utilizado para la mamografa De qu manera funciona el procedimiento Cmo se realiza Qu experimentar durante y despus del procedimiento Quin interpreta los resultados y cmo los obtengo Cules son los beneficios y los riesgos Cules son las limitaciones de la mamografa

Closing the Loop Integrating patient information material into electronic systems for test ordering and follow-up Patient portals

Integrated Care: From Medical Homes to Medical Neighborhoods Concept of Accountable Care Organizations True integrated delivery systems (SFGH and SF clinic system, Kaiser Permanente, Geisenger) Virtual organizations that are more functionally integrated

Heightened Pressures for Accountability Systematic measurement and reporting of quality, patient experience, costs Emphasis on integration and coordination of comprehensive care Patient-centered and culturally competent Accountable for a defined population Alignment of incentives to reward quality and efficiency (FFS with risk sharing, bundled payments, capitation)

The Way to Integrated Care Information technology is a tool Incentives Organization Strategy Culture The Patient 3 Care 1 Care 2 Care

envisioning integrated communication across the primary care and diagnostic service interface...

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