Sections 2 and 3 of this report described how providers are redesigning care processes and rooting out wastes and inefficiencies-with the overlapping goals of improving quality and reducing costs.
These are vital endeavors. But the ability to deliver the highest quality and most efficient care possible may not be good enough-if not all patients can access that care, if needed information cannot be exchanged between care sites, or if there are not enough physicians, nurses, or other caregivers to provide care.
In other words, to truly improve the health of the population, providers need to find creative solutions to critical problems-from workforce shortages to a lack of interoperability-that are impeding the successful delivery of quality care. This section highlights how providers are beginning to address some of these behind-the-scene issues through the use of technology.
This is part of the Leadership Fall-Winter 2010 special report, Striving Beyond Reform
Return to the full report.
Grinnell Regional Medical Center (GRMC) first considered eICU-electronic intensive care unit-technology as a lure to recruit a badly needed internist to the 81-bed hospital in the middle of Iowa. But the capacity to keep critically ill patients in their hometown hospital has brought other benefits as well.
"The eICU is a perfect example of how technology is creating opportunities for community and rural hospitals to be able to continue to provide services in their communities," says Todd C. Linden, GRMC's president and CEO.
Since 2009, the eICU technology has linked GRMC's critically ill patients to critical care physicians and nurses at the Mercy Health Network about 55 miles away in Des Moines. Using computers, two-way cameras, and video links, information is exchanged in real time, allowing GRMC's physicians, 10 critical care registered nurses, and six nursing technicians to be supported by Mercy's eICU critical care team.
GRMC currently uses two eICU mobile workstations, which can be moved to any of the five ICU beds or two emergency department trauma bays as needed. Linden expects to add more eICU systems in the future.
Recruiting physicians. Linden first explored the eICU as one solution to a staffing problem. Three internists who served as GRMC's hospitalists had all moved away, forcing the hospital to transfer its sickest patients to Iowa City or Des Moines. As Linden began recruiting an internist to move to Grinnell, he thought of an idea to sweeten the offer.
"The eICU lets our physician go home after taking care of sick patients all day. She can get a good night's sleep knowing that her patients are being well cared for," he says.
The incentive worked. By acquiring the eICU technology, GRMC was able to hire a new hospitalist, maintain its ICU, and actually improve the quality of care delivered there. The remote monitoring system is designed to alert caregivers to subtle changes in a patient's health metrics that simple observation might not catch. In addition, it allows for a different level of around-the-clock care. Since going live at GRMC with the eICU in 2009, there have been 70 interventions by the Mercy physicians that occurred during the night shift.
"In the typical community ICU, the patient is managed during the day and usually simply monitored at night," says Linden. "In the eICU, you've got active management 24 hours a day, often reducing the length of stay and improving outcomes."
Overall, there has been a slight increase in the average monthly ICU patient census-from 26 to 28 patients-since the eICU program began at GRMC. Although this is only a slight increase, it occurred during a time when overall inpatient census decreased because of the recession and the shift from inpatient care to outpatient services.
Collaborating with larger systems. GRMC is the first rural hospital in Iowa to use an eICU system. By being the pioneer, GRMC received a favorable fee arrangement in return for helping Mercy develop its protocols for interacting with other potential eICU clients in the future.
The eICU has had a positive impact on hospital finances, says Linden, although calculating a reliable ROI is very difficult. The most valuable part of eICU capability is to have the extra monitoring of the eICU patients during times when our hospitalist is not available to provide the best care for our patients.
"The eICU has had a positive financial impact because our patient census is going up in our ICU. Plus, we were able to recruit an internist, and we believe it's going to help us continue to recruit internists," says Linden. "So there are much greater benefits than just counting up our ICU visits."
While rural hospitals like Grinnell are improving the quality of care via telemedicine-type technology, large health systems are also gaining valuable benefits by hooking up electronically with other providers.
Take PeaceHealth, a seven-hospital system that serves Washington, Oregon, and Alaska. Back before many hospital leaders knew what the term electronic health records (EHRs) meant, PeaceHealth started building an EHR system that would link all providers in the communities it serves. The health system developed its vision for the Community Health Record (CHR) in 1994. In 1996, PeaceHealth hospitals began installing EHR technology.
"We chose the name 'Community Health Record' to imply that the record would span the continuum of care-hospitals, clinics, the outpatient environment, and home-and also to show that this would be a community asset that was used to improve the quality of care," says John Haughom, MD, senior vice president of clinical quality and patient safety at PeaceHealth. "We felt that it was a necessary infrastructure to support the integrated care delivery system."
Guiding cross-continuum process improvement. Today, the PeaceHealth CHR is a database that includes information about 1.8 million patients in three states.
Among other attributes, the CHR is improving patient health. Nearly 1,800 expert rules are embedded into the system to support physician decision making. And the system allows retrospective analysis of patient records to identify what works and what can be done better.
For example, PeaceHealth cardiovascular physicians have used CHR data to guide process improvement activities that have reduced door-to-balloon time for heart attack patients to an average of about 60 minutes, well below the goal of 90 minutes set by the American College of Cardiology.
"In one of our regions, we have demonstrated that over about a year and a half we have saved 85 lives," says Haughom.
Improving coordination. PeaceHealth's 7,500 employed physicians, nurses, and other caregivers use the record, of course-but so do another 16,000 clinicians in PeaceHealth's service area. One them is Melissa Edwards, MD, a gynecologist at 16-physician Women's Care in Eugene, Ore.
"I access it multiple times a day," she says. "It is an integral part of the daily functioning of any physician in this community."
The CHR provides a repository for most the laboratory, imaging, and outpatient pathology reports for Edwards' patients-because PeaceHealth is a primary provider of diagnostic services for the community. Edwards checks the CHR to track the progress of her hospitalized patients. And if a patient mentions that her primary care physician recently ordered a cholesterol test or a CT scan, Edwards pulls up the CHR to check the results.
Gearing up for the next stage. Edwards is president of Medical and Surgical Specialists, a collaboration of seven independent specialty groups that shares its own EHR system. When those physicians made their purchasing decision three years ago, they opted for one specifically for ambulatory practices rather the hospital-oriented system PeaceHealth uses. A large multispecialty clinic in Eugene uses yet another system.
"That's going to be the biggest challenge going forward: How do we start to link up these various EMRs in a way that will really move the CHR to that next level?" says Edwards.
Haughom says that is the challenge of the day, a side effect of PeaceHealth's leadership in proving the value of sharing patient information. For many years, PeaceHealth executives worked to encourage physicians to participate in the community enterprise; now the tables have turned. "In all of our communities we serve, between 80 and 100 percent of the independent physicians now have EHRs. Now they are pushing us to aggressively link in to our CHR," he says.
More than 30 percent of primary care physician visits at Group Health Cooperative, which serves Washington state and parts of Idaho, are now conducted through secure electronic messages-like email exchanges through the health system's patient website MyGroupHealth.com. Additionally, each month, 10 percent of Group Health members review medical test results online, 10 percent go online to request medication refills, and thousands of patients schedule their own appointments after checking their physicians' availability.
Electronic communication with patients is a key part of Group Health's medical home approach. The integrated delivery system, which combines a 988-physician multispecialty group practice with a 630,000-member health plan, is a national leader in implementing this alternative primary care delivery model.
Tying technology to medical homes. Group Health connects with patients through the patient website (MyGroupHealth.com) of its EHR. Group Health began investing in EHR technology nearly a decade ago, as part of an initiative to improve access, boost physician productivity, and improve the organization's overall financial performance.
EHR technology did help improve productivity. Physician panels swelled to 2,300 patients-but physician burnout ensued.
In 2006, Group Health transformed one of its Seattle-area clinics into a primary care medical home model. The pilot clinic reduced the size of its physician panels and added an array of other staff to build stronger relationships with patients, increase care coordination-and address the problem of physician burnout. Based on the successful results of that experiment, Group Health has converted all its 26 clinics to the medical home model.
The medical home uses a staffing model that allows for longer patient visits and daily time allotted for staff members to plan and coordinate patient care. Indeed, the physician panels are down to 1,800 patients. For every 10,000 patients, Group Health employs 5.6 physicians, 5.6 medical assistants, 2 licensed practice nurses, 1.5 physician assistants or nurse practitioners, 1.2 registered nurses, and a clinical pharmacist. This was a staffing increase of 15 to 18 percent for physicians, medical assistants, and nurses; 44 percent for physician assistants; and 72 percent for clinical pharmacists.
President and CEO Scott Armstrong is expecting a huge ROI from the medical home initiative. Group Health has invested $10 million to extend the model to all clinics and, based on the results of a two-year pilot, it expects to generate annual cost savings of $40 million in 2011 and thereafter (Meyer, H., "Group Health's Move to the Medical Home: For Doctors, It's Often a Hard Journey," Health Affairs, May 2010, vol. 29, no. 5, pp. 844-851).
Adding up the benefits. "There are a lot of ways that electronic communication with patients reduces the cost of your operation," says Gwen O'Keefe, MD, medical director for informatics and quality.
For one thing, electronic communication has allowed Group Health to reallocate many staff members who used to spend all of their time on the telephone with patients. When Group Health began allowing patients to look at their physicians' schedule and book an appointment online, the phones stopped ringing so often.
Meanwhile, the no-show rate for in-person appointments made online is lower than for appointments made over the telephone, says O'Keefe. Patient satisfaction is higher, and they are less likely to go elsewhere looking for medical services. "One of the goals of any healthcare system is to reduce churn of patients, and this definitely helps with that," she says.
In fact, a survey of Group Health patients found that those in the medical home clinic reported higher satisfaction with coordination of care, access to care, quality of physician-patient relationships, and patient satisfaction and involvement.
The real ROI, however, comes from the utilization patterns for patients in a technology-enabled medical home pilot clinic. These patients had more communication with caregivers despite fewer clinic and hospital visits, compared to patients in other clinics (see the exhibit below).
The bottom line: The cost of providing primary and specialty care increased in the medical home model, but the reduction in inpatient, emergency, and urgent care visits more than offset that. Group Health estimates a total savings of about $10.30 per member per month.
For every $1 Group Health invested in the medical home pilot, it has saved $1.50. Although the EHR technology and patient website are essential to success, this ROI calculation does not include technology costs because the system had already invested in its $40 million EHR system before the pilot was conceived.
Getting patients and physicians on board. With seven years of experience using electronic communication to engage patients, Group Health has a lesson to share with others: While worth the effort, this work is not easy.
"The two most important keys are overcoming physician resistance and assertively marketing electronic communication to patients," says O'Keefe. Group Health highlights its online communications options in its advertising campaigns, but it does not wait for patients to initiate online access themselves. "We work with our front office staff to get patients signed up any time they come into one of our clinics," she says. "Patients very much want to have this convenience of being able to do this, but physicians are initially skeptical."
All Group Health physicians are salaried, so the issue of reimbursement for online communication with patients is not the barrier for Group Health that it is for some other providers. Still, many physicians fear they will be inundated with messages from their patients-until they start interacting with patients online.
"Until they experience it for themselves, physicians are not necessarily going to believe this-but patients don't really take advantage of the opportunity to communicate electronically," she says.
O'Keefe suspects that the process of logging into the MyGroupHealth website reminds patients that they are interacting with a healthcare professional and this isn't the place for meaningless chat. Group Health physicians are expected to answer secure messages from their patients within 24 hours. Although a few physicians continue to dislike it, most have fully embraced electronic communication as a significant part of their practice within a couple of years. "Our younger physicians now say they cannot imagine practicing any other way" says O'Keefe.
As health systems strive to provide more care at lower costs, leaders are leaning on technology-and to good effect.
Smart Hospital Rooms
"Smart room" technology at the University of Pittsburgh Medical Center (UPMC) automatically provides caregiver-specific information on a monitor near the patient's bed when the nurse, physician, or other caregiver enters the room.
First tested at UPMC Shadyside, the SmartRoom capabilities have been expanded to 24 rooms at UPMC Montefiore in Pittsburgh. Using small ultrasound tags, the SmartRoom system identifies healthcare workers wearing the tags as they walk into a patient's room, displaying the person's identity and role on a wall-mounted monitor visible to patients.
At the same time, the SmartRoom solution automatically provides the clinician with relevant, real-time patient information pulled from the electronic medical record, including allergies, vital signs, test results, and medications that are due. The information shown on the caregiver's monitor is tailored to the needs of the specific worker. A hostess who delivers meal trays, for example, will see only dietary orders and allergy information. A physician will see different information than a nurse.
"Our SmartRoom solution tackles the everyday problems of simplifying workflow, making documentation easier and giving nurses more quality time at the bedside," said Michael Boroch, CEO of SmartRoom, a company wholly owned by UPMC. "It's estimated that only 30 to 40 percent of a nurse's time is spent on direct care. With SmartRoom, we believe that we can raise that number for the benefit of caregivers and their patients."
Care Coordination Software
The Care Management Plus program, developed at Intermountain Health and Oregon Health & Science University, uses care managers and an electronic tracking and reminder system to coordinate care for seniors with multiple chronic illnesses in primary care clinics.
Research shows that the program increases physician productivity, reduces cost of care, and dramatically improves health outcomes for diabetes patients. Through a grant program, the Care Management Plus software is available free for primary care practices that want to adopt the model. Training for care managers and assistance in redesigning care processes is also available from OHSU.
A mobile clinic-called the Family Van-rolls through disadvantaged neighborhoods in Boston each week, screening, testing, and coaching patients on nutrition, diabetes, heart disease, and other health concerns.
A service of the Harvard Medical School, the van is staffed by medical, dental and allied health students who use portable screening tools to identify high-cost conditions such as diabetes and hypertension. The program's goal is to train people to prevent and manage chronic disease and maintain overall good health.
Because the van accepts walk-ins and does not charge insurance copays, patients show up for blood pressure monitoring and other preventive services more frequently than they would if they had to book appointments at a regular clinic. The van serves about 5,000 patients a year and costs approximately $500,000 to operate.
Researchers at Harvard have calculated that, for every $1 invested in the Family Van in 2008, a total of $36 will be saved over time. Other mobile clinics that have used Harvard's ROI calculator report a 20:1 ROI.
High-Tech House Calls
Wireless access to a patient's electronic medical record lets clinicians with the Washington Hospital Center view lab results, X-rays, and specialty consults alongside the patients during a home visit.
The Washington, D.C., house call program is one of many such programs around the country that serve elderly or disabled patients who have trouble getting to physician clinics. And many more programs will start soon: a nationwide house call demonstration project will start in 2012, courtesy of the Affordable Care Act.
The physicians and nurse practitioners who conduct calls carry some high-tech devices in their black bags: miniature vascular doppler, portable EKG machines, blood analyzers, and X-ray equipment.
The Virginia Commonwealth Medical Center house calls program in Richmond, Va., has been operating for 23 years and has reduced hospital costs by 60 percent for high costs beneficiaries with multiple chronic diseases. In the Bronx, the five-year-old house call program has shown a 42 percent reduction in hospitalizations and a 33 percent reduction in total costs of care.
Several major insurers have arrangements with a technology company that connects patients and physicians any time day or night. Using a web-based interface, a patient can choose from primary care physicians and specialists who are "on duty" when the patient wants advice about a child's high fever in the middle of the night or to check out a rash without taking time off work.
Webcams allow patients and physicians to see one another, and the physician forwards notes about the encounter to the patient's medical record.
Return to the full report, Leadership Fall-Winter 2010, Striving Beyond Reform.
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