Pathology: Brief History

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Medical Homes’ Role in Advancing

Integrated Patient Care and

How Clinical Labs Add Value

James M. Crawford, M.D., Ph.D.

Department of Pathology and Laboratory Medicine North Shore-Long Island Jewish Health System

Hofstra North Shore-LIJ School of Medicine

••• • • • • • • • _{• • • •} _• • • •

Pathology: Brief History

1850 – 1920 Birth of modern Pathology/Laboratory Medicine

Vast enhancement of Population Health

1920 – 1950 Birth of modern Medical Practice

Establishment of effective therapies

1948 – 2000 Age of the National Institutes of Health

Spectacular advances by Investigative Pathology

2000 – 2010 Pivot into “Translational Research”

Evidence of effective outcomes?

Development of “Personalized Medicine”?

2010 – 2020 Leadership in Patient-Centered Care? Leadership in Population Health?

Leadership in Learning Health Systems?

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For each generation:

It is our “watch”.

The forces in motion now will determine the trajectory of our specialty for generations of Pathologists that follow us.

The Challenge

How does Pathology turn the corner

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Personalized Medicine Patient Centered Medical Home Population-based Healthcare Outcomes AC CE SS M E D IC A L S C IE N C E HIT

The National Environment

3/2009: American Recovery and Reinvestment Act

3/2010: Patient Protection and Affordable Care Act

HITEC ACO

2009 2010 2011 2012….

Electronic Health Records

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American Recovery and Reinvestment Act

2009

Page 354:

(C) NON-APPLICATION TO HOSPITAL-BASED ELIGIBLE PROFESSIONALS.—

(i) IN GENERAL.—No incentive paymentmay be made under this paragraph in the case of a hospital-based eligible professional.

(ii) HOSPITAL-BASED ELIGIBLE PROFESSIONAL.—For purposes of clause (i), the term ‘ hospital-based eligible professional’ means, with respect to covered professional services furnished by an eligible professional during the EHR reporting period for a payment year, an eligible professional, such as a

pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified electronic health records, of the hospital. The determination of whether an eligible professional is a hospital-based eligible professional shall be made on the basis of the site of service (as defined by the Secretary) and without regard to any employment or billing arrangement between the eligible professional and any other provider.

Enter the concepts of: “Patient Centered Medical Home”

“Advanced Medical Home”

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“Patient Centered Medical Home” Primary Care Practice

“Advanced Medical Home” Specialists delivering

“primary” care

“Patient Centered Medical Neighborhood” Continuity of care through all delivery sites

PCMH: Definition

An approach to providing comprehensive primary care through a healthcare setting that facilitates partnerships between individual patients, their personal physicians, and, when appropriate, the patient’s family.

• Each patient has a personal physician

• This personal physician directs the primary medical care received by the patient • The personal physician takes responsibility for arranging care for all of the patient’s

health needs

• The personal physician coordinates the patient’s care across all elements of the complex health system

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Patient Centered Medical Home

OPERATIONAL PRINCIPLES*

• Healthcare quality and safety are integral objectives of a PCMH

• Patients should have enhanced access to healthcare through the PCMH • Payment for healthcare services should recognize the added value

provided to patients who have a patient-centered medical home

EXPECTATIONS

• Excessive utilization of healthcare services will be reduced • The “patient experience” will improve

• Primary Care Providers will have more time to spend with their patients • The healthcare outcomes of the population will improve

*2007: AAP, ACP, AAFP, AOA

PCMH: Brief History

1967 American Academy of Pediatrics (AAP): concept of a chronic care “home” 2001 Institute of Medicine (IOM) report: Crossing the Quality Chasm: A New Health

System for the 21st_Century

2005 Institute of Medicine (IOM) report: Building a Better Delivery System: A New Engineering/Health Care Partnership

2004 American Academy of Family Physicians (AAFP): endorses PCMH 2006 American College of Physicians (ACP): endorses PCMH

American Osteopathic Association (AOA): endorses PCMH 2006 Patient Centered Primary Care Collaborative (PCPCC) established 2007 Joint Principles for PCMH articulated by AAP, AAFP, ACP, AOA

National Committee for Quality Assurance (NCQA; founded 1990) incorporates

Joint Principles into their “Physician Practice Connections” (PPC) guidelines

2008 NCQA begins deeming physician practices for meeting PPC-PCMH standards 2009 American Recovery and Reinvestment Act (ARRA): $30B of adoption incentives for

“meaningful use” of certified Electronic Health Records (EHR) : Medicare Initiation of numerous Medicare demonstration programs

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PCMH Activities

• Enhanced Access

• Team approach

• Registries (pop. mgmt)

• Active care coordination

• Quality and safety systems

• Advanced patient engagement

• Information systems foundation

The PCMH “requires a new “mental model” of how primary care delivers value” David Nace, 2010

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Direct Patient Care Care Coordination Patient Education Prevention 0 2 4 6 8 10 12 14 16 18 20

Physician (Based on a panel size of 2500 patients)

H our s / D a y 7.4 hours/day 2 hours/day 2 hours/day 7 hours/day 8 Hour Day Practice improvements often fail because they rely on the willingness of physicians, who are already too busy, to take on additional work. - Tom Bodenheimer

Taking care of patients

Hours required for full portfolio of care

Direct Patient Care

Optional

David Nace, 2010

Patient Centered Medical Home

Building a team model

16 14 12 10 8 6 4 2 Patient Flow Manager Physician Care Manager Midlevel Pharmacist IT Hours/Da y David Nace, 2010

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Patient Centered Medical Home

Key Components of a Transformed Practice

Comprehensive Care

Patient Engagement

Enhanced Access Coordinated Care

Team of Providers EHR with Registry Function

Additional non-physician providers support medical home’s ability to provide additional services

Provides data around key patient metrics to help track and monitor patients allowing for improved overall patient management

David Nace, 2010

The value proposition for the PCMH*

INTEGRATED DELIVERY SYSTEMS (for example)

• Group Health Cooperative of Puget Sound: 0.2% PMPM decrease for PCMH patients; 16% decrease in hospital admissions.

• Geisiger Health System PCMH model: 7% PMPM decrease for PCMH patients; 18% decrease in hospital admissions.

• VA Midwest Healthcare Network (VISN 23):

27% decrease in hospital admissions/Emergency Department visits

• HealthPartners Medical Group/BestCare PCMH Model: 8% decrease in overall costs 24% decrease in hospital admissions; 24% decrease in Emergency Department visits • Intermountain Healthcare Medical Group Care Management Plus PCMH Model:

25% decrease in hospital admissions for diabetics; $53 PMPM reduction

*Grumbach K, Grundy P; 11/16/2010

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What is the role of Pathology in “Patient Centered” Healthcare?

Patient Centered Medical Home

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Patient Centered Medical Home

David Nace, 2010

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Patient Spe cialis_ts Reh abili_tatio n Acute Care Home Care Imaging Labs Insurance Employer Community

Patient Centered Health Care

ca. 2010 Patient Spe cialis_ts Reh abili_tatio n Acute Care Home Care Imaging Labs Insurance Employer Community

Patient Centered Health Care

ca. 2010

frustr_ation frustr_ation

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The position of the Office of the National Coordinator*

• It is the local multistakeholder alliances that will effect change.

• Information is the lifeblood of medicine.

• ‘Meaningful use’ is the key to unlocking the potential of Health IT for Primary Care, Specialty Care, and Hospitals, because it focuses not on the technology but on its use.

• Five domains of focus:

- Quality, Safety, Efficacy, Access - Public and Population Health

- Engagement of Patients and Families - Coordination of Care

- Privacy and Security

• These domains accord perfectly with the PCMH.

*David Blumenthal, 3/30/2010

Information Management Requirements†

Patient Access and Communication appointment scheduling

clinical information/PHR* education information

self-management support

Patient Tracking and Registry organizing clinical data*

managing disease conditions*

Care Management guidelines, Decision Support*

electronic prescribing

test tracking* tracking referrals

tracking Continuum-of-Care*

†_{National Committee for Quality Assurance 2008}

Patient Centered Medical Home

*Pathology: primary data or potential coordinator

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Performance Reporting and Improvement Measures of physician and practice performance*

Measures of healthcare outcomes

Safety and Quality of healthcare*

Specific disease management outcomes*

Patient experience and satisfaction (Note: role of Phlebotomy services) Ed note: These tools help the physician practice achieve improved outcomes;

they are not construed as a “policing” function

National Committee for Quality Assurance 2008

Patient Centered Medical Home

Patient Management

Previsit planning (Laboratory testing*,Radiology testing, Dietary restriction)

Patients needing clinical review or action* Monitoring patients on specific medications

Patients needing reminders for preventive care, specific tests, follow-up* Patients who might benefit from care management support*

Patient Centered Medical Home

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Population Management Integrated clinical data from all care sites*

Integrated ancillary data (e.g., all laboratory tests, all referrals)* Healthcare Resource utilization

Physician office visits, use of ancillaries, need for acute care* Real-time tracking of Claims data*

to include use of Pharmaceuticals*

Real-time tracking of Safety and Quality Outcomes* Real-time tracking of the Patient Experience* Disease Management Outcomes*

Biometrics (e.g., weight, body-mass index, blood pressure)*

Laboratory values as primary data on patient status(e.g., HbA1c, lipids)* Data on Lifestyle management (e.g., activities, dietary education)*

Patient Centered Medical Home

Clinical Endpoints Resolution of medical condition(s)*

Addition of co-morbid or new conditions* Escalation of care environment*

Acute-care intervention (e.g., hospitalization, surgery)* Death*

Patient Centered Medical Home

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Outcomes Assessment Physician Practice outcomes*

Testing of Evidence-Based Medicine within your healthcare organization* Testing and validation of Safety and Quality initiatives*

Identification of Adverse Events* Patient Compliance*

Efficacy of Lifestyle, Wellness, and Disease Management programs* Access to Preventive Screening programs*

Delivery of healthcare at lowest cost service location*

Return-on-investment of HIT solutions and the PCMH*

Data on Lifestyle management (e.g., activities, dietary education)*

Patient Centered Medical Home

There is no current payment model for these “pathology” activities - ? Consultation for appropriate test utilization ?*

- ? Access to “pathology-specific” demonstration projects ?*

We are excluded by federal law from receiving “practice” payments. Attribution – and Distribution – of “shared savings” is yet to come. When (not “if”) ‘Bundled Payments’ arrive, the allocation of funding will

be a local event.

Where will Pathology/Lab Medicine be if not already recognized locally for our value proposition in patient management?

Payment issues

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You can’t retrofit Laboratory into the Medical Home/ACO model. You have to be part of the design in order to pre-establish your value.

What-if

Master Patient Registry

Laboratory Information System

In-Patient EHR Ambulatory EHR

Registration and Billing

RHIO Patient Experience

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The Learning Healthcare System

(1) EHR Database Biostatistics (2) Research Output

(3) Occupational Health (4) Genomics

♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Physicians

Patient EHR Record

(5) National Benchmarking (2.1) Laboratory Data

Claims

NSLIJ “Current” Physician Network

Hospitals Ambulatory Care Network

Acuit y $

$

MG PCP* Affiliated Inpatient Revenue = 64% Outpatient Revenue = 36% 2010 Market Share = 26% MG Specialties

*MG PCP: Medical Group Primary Care Providers

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NSLIJ “Value-Based” Physician Network

Hospitals Ambulatory Care Network

$

Affiliated MG PCP Market Share ? ? MG Specialties

Pathology: supporting Physician Offices; sourcing data for network

Department of Pathology and Laboratory Medicine

NSLIJ HS:

Ambulatory EHR Ambulatory Care Network

NSLIJ Laboratories: uniform Laboratory Information System Integration of service units

Integrated business/leadership model

NSLIJ HS Physician Practices Patient-Centered Quality Outcomes Population-based Improved Healthcare Outreach Physician Practices Penetration of market ATLAS, Other AllScripts Convergent Objectives: 2010-2012

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Find the “strongest signal” in your

local healthcare environment

Work with those stakeholders.

Make your own business future.

The Role of Pathology/Lab Med

• Primary informant on “absolute” measures of health status. • Colleague to physicians across the continuum-of-care:

- Mastery of disease pathobiology

- Medical Director of all clinical diagnostics

to include: advanced diagnostics of “Personalized Medicine” - first Providers to “see” the data readouts

- Responsible for the largest single source of medical data - Expert on data analytics, population outcomes

• System expert in effective delivery of healthcare resources. • Get involved locally: Health System

Ambulatory Care Network

Primary Care Physician Practices Civic agencies, local employers

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The Message

• Pathologists should actively seek participation in demonstration pilots: PCMH, Coordinated Care, EHR (and PHR) deployment. • Pathologists should be drivers of EHR (and PHR) data flow. • Pathologists, as integral members of the Coordinated Care

Team, should be experts on test selection and interpretation for individual patients.

• Pathologists should inform regional practices on test utilization across populations, to ensure safety, efficacy, and utility.

Expert, Teacher, Scholar, Advocate

Most importantly:

Pathologists/Laboratory Directors are leaders first, and utilize their extraordinary professional skills to promote improved healthcare outcomes across the populations they serve.

Corollary:

Pathologists/Directors have to step forward as leaders within their regional health systems (however integrated or fragmented such systems may be).

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Ergo

Pathologists and the Clinical Laboratory have a central role to play in the Patient Centered Medical Home, the Medical