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iHT2 Health IT Summit in San Francisco 2013 - Dr. Sean Rogers, Medical Director, Bend Memorial Clinic, Case Study "Using Health IT for PCMH, Accountable Care and Population Health"

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Dr. Sean Rogers …

Dr. Sean Rogers
Medical Director
Bend Memorial Clinic

Case Study "Using Health IT for PCMH, Accountable Care and Population Health"

Learning obectives:

∙ Discuss how Bend Memorial transitioned to the patient-centered medical home delivery model
∙ Understand the key healthcare IT solutions toward population health management
∙ Identify key technologies and registries for patient outreach and patient engagement
∙ Discuss the quality and outcomes achieved for Bend Memorial (reduced admissions, reduced ED visits, and enhanced chronic care management)

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  • 1992 Presidential Campaign – James Carville is the campaign strategist for Bill Clinton. He puts a sign up in campaign headquarters to help staff stay focused on the important issues:Change vs. more of the sameThe Economy, StupidDon’t forget healthcare
  • Map of 34 OECD nations (in color). Only 3 do not have universal health coverage – US, Mexico, and Turkey
  • We have a social imperative to move from: 1) volume to value2) quantity to quality3) episodic care of individuals to longitudinal care of populations4) claiming excellence to proving excellence.  I have yet to meet a doctor who thinks that he or she is below average -- everyone thinks that they are great.
  • Triple Aim -- Improving the individual experience of care, improving the health of populations, reducing the per capita cost of careWho could argue with that?  It sounds great!The main problem with the Triple Aim is that it is not a goal -- no specifics, no timeline.  It's like a coach telling an athlete to get better versus setting a specific goal with a specific timeline
  • JFK and the moon shot -- now that was a goalIt was specific, actionable, and time limited.Healthcare in America today needs such goals.So how DO we convert the concepts of the Triple Aim to goals that are specific, actionable, and time limited?
  • Enhanced Access – same day appointment slots, expanded after hours access, in-house UCC access 365 days/yearPersonal Physician – focused effort re: attribution and getting patient in to see their own physicianPhysician-led team-based care – nursing staff, care manager, pharmacist-driven protocols, behavioral health, nutrition. Everyone working to the height of their licenses4) Whole Person Orientation – acute and chronic care, preventative screenings, end-of-life care 5) Coordinated and Integrated Care – seamless communication within EHR, population management, patient outreach, transition of care coordination, patient engagement, monitors patient care regardless of site6)Quality and Safety – EBM, PSS, QM tracking and reporting, Disease registry, regulatory compliance, CPOE, E-Rx, MU attestation7) Payment Reform – innovative model with local payer (FFS + PMPM + SS + Quality bonus)


  • 2. It’s thePatient, Stupid
  • 3. Healthcare in America – 2013 10K Baby Boomers turn 65 every day Looming Medicare insolvency Misaligned payment incentives Inequitable access and spending Focus on acute, episodic care
  • 4. Triple Aim Improving the individual experience of care Improving the health of populations Reducing the per capita cost of
  • 5. New model of care: Population HealthManagement Traditional View New View 30 Patients Per Day 2500 Patient Population Fee for Service PCMH Accountable Care
  • 6. Enhanced Access Payment reform QualityPersonal andPhysician Safety Physician-led Coordinated and Team-based Whole Person Integrated Care Care Orientation
  • 7. Patient-Centered Medical Home Right Care Right Patient Right Time Right Location
  • 8. HIT and Population Health EHR Patient Portal Electronic disease registry Patient outreach Quality metrics reporting Referral tracking Transition of care coordination PHI access for external providers (read-only access) Clinical decision support HIE Predictive Modeling
  • 9. Data Sources EHR PM Claims data Enterprise Data Warehouse Manually input discrete data  Medical Home notes
  • 10. Lessons Learned – Must Haves Communication is critical Physician champions Senior management buy-in Adequate resources Data validation Maintain a sense of urgency
  • 11. Guiding Principles Truth is hard Change is ever-present Constancy of purpose Take the long view Nothing is trivial Make a conscious decision to be successful
  • 12. Contact InformationM. Sean Rogers, MDMedical DirectorBend Memorial ClinicBend, OR 97701srogers@bmctotalcare.comCell 858-733-1421
  • 13. Additional Material
  • 14. BMC Medical Home Same Day Appointment slots Team-based care Using staff to the height of their licenses Standardization/Optimization  Exam rooms  Physician/Staff Work flow  Task Management  Supply ordering  Check-in and Check-out processes
  • 15. BMC Medical Home (cont’d) Updates occurring every patient, every visit  Vaccinations  Medications  Health maintenance  Creation of Medical Home notes Care Manager Pharmacy integration  Medication Refill protocol  Patient counseling  Prior authorization