Ed Goldman

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Patient Centered Medical Home Future of Medicine Summit
Palm Beach County Medical Society and Florida Public Health Institute

Sam Bierstock, M.D. BSEE,
Founder and Principal, Champions in Healthcare

Can we really prevent disease?
Can it be done in a primary care settings?

Category: PBCMS
Date: November 3, 2007
Views:7,106 views

We inadvertently wandered into the medical home without even realizing it. MVIP which I represent started about a decade ago at a dinner just south of here in Boca Raton. And it started with a group of doctors sitting around a table asking that question, could we really prevent disease and if we could prevent disease how could you do it in a primary care form? At the time we weren't really sure we could but the discussion, rather than just being a dinner meeting, broke up and then we started to pursue this further.

We talked to George Blackburn at the Harvard School of Epidemiology, Mike Hatwick who is in charge of prevention for Blue Cross/Blue Shield. And we looked about definitions, primary, secondary prevention and risk factors. And we concluded that yes, you could stop disease by addressing risk factors, by modifying them. And then we tried to see, could you do it in a primary care setting?

What we ended up doing was starting a bunch of focus groups with physicians literally across the nation. We asked them two questions. If you were going to do the same physician exam that Mayo Clinic does, not testing but doctor/patient time, how long do you think that would take you? The consensus was probably about an hour. And then we said, okay if you were going to give the patient a health risk assessment, discuss their risk factors with them, talk to them about how they could get further education and then follow them over the course of the next year in a wellness plan to modify those risk factors how long do you think that would take? Blank. Because we don't practice medicine that way.

But we pushed them to give us an estimate and it was, well probably at least another hour, hour and a half, over the course of the year, either directly or when they came in for other illnesses. Well then we were up to two, two-and-a-half hours per patient. The average primary care practice has 2300 patients. There aren't enough hours in the year to do that. So we went back to the drawing board, looked at how many patients go to the doctor in different age cohorts; at 30, 40, 50, 70. And we determined that we could be the primary care physician and do this program for only about 600 patients.

At the time we went to one of the major health care providers to look for a demonstration project and the medical director stopped in the middle of it and said, "Let me understand this. You want me to pay you more to see less patients? Come back when you have the data to show me you can save me money."

We didn't get a very good reception in Washington either. So we hired out the Hilton Hotel in Boca Raton and we invited all the patients in their practice to come to it. And we said, "Listen, we'll do the same physical that the executives receive at Mayo from their corporations sending them there. On every one of you we'll also put in all of this infrastructure of prevention. But it's going to cost you $125 per month over and above your insurance. And to our surprise we signed up 600 patients that night. And ten years later we have continued to do exactly that.

The premise that we use, they're first to prevent diseases from occurring by modifying risk factors to detect them before they're symptomatic, and to manage existing diseases through evidence-based protocols. We have put together a comprehensive plan that does health risk assessments, that does comprehensive evaluations and screenings, that does an individualized wellness plan for every single patient. We give our practices electronic medical records just for being affiliated with us because it's too hard to get practices to bite the financial nut alone. We have put together a collaboration of the finest universities from Mayo and Cleveland Clinic to Johns Hopkins and UCLA, all across the nation, that we collaborate with, that we get second opinions from, that we can interact with or even send our patients to. And then we've developed communication systems so the patient and the physician can be in contact without being in the office.

We have changed the definition in our world of what the primary care physician does. He needs to assess a member's health. He needs to educate that member with respect to disease prevention. And then he needs to follow up and be the advocate in terms of prevention. We have now grown to about 340 practices, about 100 - since we updated about 130,000 patients. We're in 28 states and D.C.

We do this program continually for every single patient in our practices and we have demonstrated and soon will be published on dramatic reductions in hospitalizations and increase in patient satisfaction which we think are some of the first data coming in on the medical home. We have developed integrated IT systems from our own shop that allow us to deal with what we need to deal with.

And some of the problems we run into, I won't take any real time to talk about it, are individualized practicing primary care. So you can give a patient a health risk assessment and guess what - and I take an extreme example when I do this - guess what? If they're a smoker and they have a family history of heart disease and elevated cholesterol they're going to show up high risk on any health risk assessment. Except if the patient has bronchogenic carcinoma, and they don't need to be terrorized with the fact that they're going to get a heart attack. So the physician needs to interact in all of the risk factors and determine what's clinically significant, and what's not significant. We've gone through all that in terms of the electronic record because we're distributed over the nation.

And so what happens if the Internet goes down? We've had to be creative to develop systems that would be back up to let the physician continue to practice even if the Internet wasn't there. Our information systems look pretty much like what you're seeing. We have a physician portal, a patient wellness portal. Rather than taking a WebMD approach each of our patients has their own individual Web site. WebMD doesn't know what's pertinent to you; you have to search for it. But I'm your physician; I know what's pertinent to you. And so I can give you just the information you need to interact in your own wellness and to be an advocate on behalf of your own health. We take all of our practices, download the data into a data warehouse so that we can understand what works and what doesn't work. We do individual practice Web sites and we're just now starting to talk about doing cell phone applications to remind patients to take meds, to query them of side effects when we prescribe meds.

I'll go through some screens quickly. This is our health risk assessment, easy for patients to understand and see. We work with Duke University. Once you get a health risk assessment you get a red box chart. Each red box is a modifiable risk factor. And then we use a series of tutorials and Web based information systems to educate the patient. And then we track all of the risk factors. If you're supposed to exercise, log on and tell me what your exercise is. Let's track your blood sugar, your blood pressure, your cholesterol, your calories, your fiber, whatever we need to and let's make that information easily obtainable by the physician so that we can manage what you're doing. When you're into modifying risk factors and prevention treatment can't start and stop at the waiting room door. It's a lifestyle change and lifestyles go on where life is. And so we needed to create the systems that allowed the doctor and the patient to interact real time whenever they needed to.

We are in the final throws of our personal health record which will take everything in the electronic medical record and put it on the patient site so that they can see what their records are and they can interact with the office on the basis of that. We have our own HIPAA secured communication; for appointments, for medication refills, for messages. And then we have a physician site where everything is available by icon. So if you're on your iPhone and you need to look up a med chart or you need to look up a patient record you can click and do exactly that. The problems that we've run into along the way are a whole different discussion. But we have solved each of them in terms of what's relevant to the patient and what works.

Along the way we started to gather data. We survey every practice once a month for 72 areas of patient satisfaction. We presented our [hedist compliant stat] at the American Public Health Association. We're compiling it right now; we think it will be better than 90% compliance. And over the past four years, soon to be published, we have reduced hospitalizations by almost 50% by doing this patient-centered care. When we started finding the principles that [Sherry] talked about, physician directed practice, personal physician, whole person orientation, we looked around and said, "Goodness, it sounds a lot like what we do." So we started to look at the - at what you needed to do to coordinate this. This slide I borrowed from [Greg Rowan] at Cincinnati. We are all in the bottom rung today.

We have really a disoriented, disordered system. And to be a medical home you really need to manage chronic disease, manage transition from hospitalists and hospitals back into the practice, manage the communications and outpatient care with families, with the patient. And even manage our own practices so that we can do that type of longitudinal follow up. It is a very tall order for a primary care physician's practice to be able to do this.

We looked at the NCQA aspects of care that were measured and literally went through each measurement criteria and started to apply them to our practices because we are now in the process of taking about 340 practices and certifying them all as medical homes. And so what we concluded is that we were going to go for a Level 1 certification for any practice that did not currently have implemented an electronic medical record. It was just too hard to meet all the criteria on paper. But we were going to go for Level 3 certification for all of our practices that do have electronic medical records where we can go through at nauseam the implication of what's being measured.

What we did is we actually produced a resource assessment. We looked at every parameter that was going to be measured. We looked at what was "must pass" and what wasn't "must pass" so that we knew where to put our emphasis. We looked up what our systems have that would meet the criteria of the NCQA and what the practices had in their own systems. It doesn't all have to be electronic. It could be paper charts. As long as you have a problem list you could meet a criteria. As long as you have a med list you could meet a criteria in the chart without being electronic.

And so we went through and saw exactly what resources the practice had, what we had. And for each practice then we could elaborate a plan for what they needed to do to become certified. And we're in the process - right now we're across the nation.

I will tell you that we've learned certain things. The first is that you need to understand that this is a time commitment. This is not something you're going to do without really a lot of involvement. And it's going to cost. It's going to cost in two ways. It may cost in actually purchasing systems that comply with this, but it will certainly cost in loss of productivity from you and your staff because it's going to take your time and your staff's time to be able to do this.

We think that you can't do it without identifying a responsible person. That responsible person can't be the doctor because he's too distracted and there are too many things. It usually is the office manager. You want to make sure that there is physician buy-in. If it's a group practice it can't be just one member of the group who's passionate. It's got to be all the members of the group or it will fall apart before it starts. You've got to make sure that the staff understands what they're doing and buys-in to what they're doing. Otherwise it will be like pulling a resistant donkey to get to the finish line.

You need to make certain that you get agreement on a project time and a timeline. So you need to lay out all the steps to do this, all the time to do this. And then you need to assign tasks to people along those project lines and you need to hold them accountable for deadlines and hold them accountable for completion. You need to meet frequently because we all get busy, this becomes a backburner and you don't accomplish it. And then the best plans will be modified by the reality of what you deal with and you need to do that. You need a lot of discipline, a lot of perseverance.

But we think that it's worth it. We're totally committed to it. We think that it's better for patients and that it will ultimately be what Brian was talking about, about saving the system real dollars and by changing the fundamentals of medicine.

There are questions right now that revolve around how much coordination can a primary care physician's office do. If you have a Web of specialists and you're supposed to be coordinating things it's one thing if you're part of an integrated delivery system, it's another thing if you're the lone ranger trying to juggle all the balls in the air. And so we think that the coordinating out on what this ultimately looks like, but we are committed and believe that primary care to survive needs to be modified along these lines. Thank you.

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