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The Promise of Population Health Management


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New Technologies Are Required To Automate Expanded Physician Workflow. To create a sustainable healthcare system that provides affordable, high-quality healthcare to all, we will have to adopt a population health management (PHM) approach. While the transition to PHM will be difficult for providers and patients alike, the change could be facilitated and accelerated through the use of health information technology, self management tools, and automated reminders that are persistent in changing behaviors.

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The Promise of Population Health Management

  1. 1. PHYTEL | WHITEPAPERThe Promise of Population Health ManagementNew Technologies Are Required ToAutomate Expanded Physician Workflow
  2. 2. ContentsThe ChallengeWith the primary care workforce declining, and a bigincrease in the demand for care anticipated, access is likelyto shrink in the coming years.Pages 5-6What Is Population Health Managent?Page 6-7Obstacles To PHMPage 7-9Beginnings of ChangePage 9-10The Crucial Role of AutomationPage 10-11Three Pillars of PHMPage 12ConclusionsPage 13About the AuthorAbout Phyel
  3. 3. The Challenge: The protracted debate over healthcare reform has highlighted the shortcomingsof our healthcare system. While the Patient Protection and Affordable Care Act promises to expand coverageto more than 30 million people who are currently uninsured, this insurance will be worth little unless they haveaccess to care. But with the primary care workforce declining, and a big increase in the demand for careanticipated, access is likely to shrink in the coming years (Phillips and Bazemore).Quality is also an issue. The U.S. has a “sick care” system that is not designed to take good care ofchronically ill patients, who generate about three-quarters of health costs, or to prevent people fromgetting sick (Institute of Medicine, Crossing The Quality Chasm, 3-4). According to a famous RANDstudy, American adults receive recommended care only 55 percent of the time (McGlynn, Asch, etal.). The gaps in treatment lead to unnecessary complications, ER visits and hospitalizations—a majorcomponent of the waste in our system. So even if we had enough healthcare providers, the rising costsof chronic disease care would soon exceed our collective ability to pay for it.The fragmentation of our delivery system and the poor communication among providers are primereasons for the poor quality of care that many patients receive. For example, readmissions of patientswith congestive heart failure have been on the rise for years. Today, about 20 percent of Medicarepatients with CHF are readmitted within 30 days after discharge from the hospital. Some researchershave speculated that this may be related to shortter lengths of stay in the hospital (Bueno, Ross, et al.).But other studies show that better care management on the outpatient side could eliminate the majority The gaps in treatment lead to unnecessary complications, ER visits and hospitalizations—a major component of the waste in our system.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 3
  4. 4. of these readmissions (Berwick, Nolan and the federal and state governments are beingWhittington). In many cases, that care is not bankrupted by skyrocketing medical costs.being provided because of poor handoffs Clearly, we need a radical change. We mustfrom inpatient to outpatient care and lack of reorganize the financing and the delivery offollow-up with the patients after discharge. healthcare to provide greater value to bothIn addition, there is no financial incentive patients and society.for physicians to engage in the home care Myriad proposals have been made toof patients, beyond the general supervision restructure our system. One of the mostof home health nurses. In the case of heart promising is the “Triple Aim” of the Institutefailure, this continuous care is required for Healthcare Improvement, formerly headedto prevent emergencies that can lead to by Donald Berwick, MD (Berwick, Nolan andreadmissions. Whittington). The Triple Aim program seeks to:Except in a few large, integrated healthcare 1) Improve the experience of caresystems and government systems that takefinancial responsibility for care, physicians are 2) Improve the health of populationsnot generally paid to treat patients outside of 3) Reduce the per capita costs of careoffice visits or to coordinate their care across This paper will address the second aim,care settings. Partly as a result, the continuity “improve the health of populations.” Weof care is disrupted at many points (Sharma, believe that, by applying population healthFletcher, et al.). management principles, physicians and otherAt the same time, non-medical determinants providers can also improve the healthcareof health—which have a far greater impact experience for patients while reducing coston health than medical care—are not growth to a manageable level.being properly addressed. Overeating,smoking, unsafe sex, lack of exercise,and other personal health behaviors aremajor components of health spending, yetphysician counseling of patients is poorlyreimbursed and usually confined to office This paper will address the second aim,visits for other problems.For these and many other reasons, the “improve the health of populations.” WeUnited States spends roughly twice as much believe that, by applying population healthon healthcare as other advanced countriesdo, yet the outcomes of our patients are management principles, physicians andinferior in many respects (Davis, Schoen,et al.). Healthcare is rapidly becoming other providers can also improve theunaffordable for many people, and both healthcare experience for patients while reducing cost growth to a manageable level.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 4
  5. 5. What Is Population Health Managent?As Berwick and his colleagues point out in a paper on the Triple Aim (Berwick, Nolan, and Whittington), muchof the current quality improvement efforts, such as “pay for performance” and Medicare’s quality reportingprograms, focus on single sites of care, including acute-care hospitals and physician practices. To really makea difference in outcomes, however, reformers must try to raise the quality of care and improve care coordinationacross all care settings. Also, this approach must be applied over a much longer period than that of a singleepisode of care.These concepts lie at the core of population health management, which has been defined as a healthcare approachfocusing on “the health outcomes of individuals in a group and the distribution of outcomes in that group.” FormerKaiser Permanente CEO David Lawrence, MD, observes (Lawrence),“Patients are just one of many such groups within a community. At any given time, most people do not worry aboutillness or wonder if they have one. They are not under treatment, and they see a physician infrequently. Yet for allpeople, lifestyles and behavior; race, culture, and language skills; and the environment in which they live are allimportant determinants of their individual health…Effective population health care includes interventions to moderatethe impact of these powerful determinants [of health].”So population health management, or PHM, as we will hereafter refer to it, addresses not only longitudinal careacross the continuum of care, but also personal health behavior that may contribute to or prevent healing or disease.Based on the experience of Kaiser Permanente and other organizations that are dedicated to PHM (Lawrence book),here are some of the other aspects of this approach to care:•  An organized system of care. Healthcare providers must be organized, even if they’reonly electronically linked and have agreed to follow certain clinical protocols to improvethe quality of care.•  Care teams. Physicians and other clinicians work in care teams to provide multiplelevels of patient care and education on a consistent basis.•  Coordination across care settings. Patients have a personal physician whocoordinates their care and guides them through the system.•  Access to primary care. Primary care is vitally necessary to make sure patient receivenecessary preventive, chronic, and acute care.•  Centralized resource planning. Resources are allocated to make sure that individualpatients receive all necessary care and that available resources are optimally appliedacross the population.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 5
  6. 6. ACOs will have to stress non-visit care and disease management, includinghome monitoring of the sickest patients. They will have to build care teams thatare capable of tracking patients’ health status and ensuring that they receiverecommended care.•  Continuous care. Providers are available Cooperative of Puget Sound; large integratedto patients both during and between office delivery systems like Intermountainvisits, and all forms of communication, Healthcare, Geisinger Clinic, and the Henryincluding secure electronic messaging, are Ford Health System; and the Veteransappropriately utilized. Affairs Health System and the Military Health System. Aspects of PHM are also being•  Patient self-management education. With used in some other countries, such as thethe help of printed and online materials, care U.K. and Sweden (Berwick, Nolan andteams help patients learn how to manage Whittington).their own conditions to the extent possible.•  Focus on health behavior/lifestyle Obstacles To PHMchanges. Providers and the educational In the U.S., the biggest barriers to populationmaterials they offer reinforce the need for health management are the fragmentation ofhealthy lifestyles across the population. care delivery; perverse financial incentives; a lack of managed care knowledge; and•  Interoperable electronic health records. insufficient use of health informationEHRs are used to store and retrieve data, technology.not only on individual patients, but on thestatus of the population. They are also used According to the Institute of Medicine’sto track orders, referrals, and other care 2001 report, Crossing The Quality Chasm,processes to ensure that patients receive “The current health care delivery systemthe care they need. And by exchanging data is highly decentralized…In a populationwith other clinical systems, interoperable increasingly afflicted by chronic conditions,EHRs provide physicians with information the health care delivery system is poorlythat help them make better decisions. organized to provide care to those with such conditions…The challenge before us is to•  Electronic registries. Whether or not move from today’s highly decentralized,registries are part of EHRs, they are cottage industry to one that is capableimportant components of PHM, because of providing primary and preventive care,they enable caregivers to track and caring for the chronically ill, and copingmanage all of the services provided to or with acute and catastrophic services.” Thedue for their patient population, as well as fee-for-service reimbursement system is thesubgroups of that population. opposite of the payment approach that is suited to PHM. Fee-for-service incentivizesPHM or the major components of PHM physicians to perform more services, ratherare found mainly in group-model HMOs than helping patients get well or preventinglike Kaiser Permanente and Group Health them from getting sick. Because third-partyPHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 6
  7. 7. payers usually pay doctors only for services is going to become a reality. This includes notperformed in their offices, the hospital, or some only EHRs and health information exchanges,other institutional setting, physicians have no but also registries and applications thatincentive to communicate with patients online use clinical protocols and sophisticatedor on the phone or care for them at home. algorithms to identify individuals with careThere are perverse incentives in other payment gaps and to trigger communications to thoseapproaches, including capitation, which patients and their physicians. Despite themotivates doctors to do as little for patients federal incentives that will start becomingas possible, and straight salary, which doesn’t available in 2011, and the threat of financialencourage them to work hard (IOM, Crossing penalties later on, it will take some timeThe Quality Chasm, 181-206). But a new before most doctors and hospitals havepayment approach is needed for PHM. EHRs. But in the meantime, organizationsBecause most physicians are used to practicing that do acquire information systemsTEC plans to qualify as an ACO for Medicare’s shared-savings program in2012. The group’s leaders believe that budgeting is the future of healthcareand that ACOs could be a key driver of that the fee-for-service system, they have no idea can begin to take advantage of the newhow to manage care within a budget (Terry, 177- information technologies to practice PHM.178). Budgeting is part of the central resourceplanning referred to above. Since there are limits Beginnings of Changeto the available healthcare resources, physicians Over the past 15 or 20 years, approachesmust learn how to order tests and perform such as pay for performance and diseaseprocedures more appropriately. Many doctors management have had a very limited effectwill object that they must practice defensive on quality improvement. Pay for performancemedicine to guard against malpractice suits. programs focus on a relatively small set ofBecause physicians are so concerned about this, measures, confuse physicians with conflictingmalpractice reform could help accelerate the goals from multiple health plans, don’t rewardevolution of PHM. improvement, and often use sample sizesFinally, the healthcare industry needs to make that are too small to show how well individualmuch better use of information technology and physicians are doing on particular metricsimprove the quality of data in the system if PHM (Rosenthal, et al.)PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 7
  8. 8. Automated PHM tools ensure that the routine, repetitive work of managingpopulation health is done in the background, freeing up doctors and nurses todo the work that only they can do.Disease management, a systematic approach visit care (AAFP, AAP, et al.).to caring for patients with chronic diseases, While much progress is being made on thehas taken two different forms. The Chronic PCMH, practices that try to become medicalCare Model, a method of integrating all homes encounter some significant obstacles.of the care for particular chronic condition First, small primary-care practices may lackacross providers and over time (Bodenheimer, the time and the resources to transformWagner, and Grumbach), requires the themselves and acquire the necessaryresources of a large organization, such as a information technology (Nutting, Miller, et al.);group-model HMO, and cannot be readily second, they may find it difficult to gain theapplied in small practices, although they can cooperation of specialists and hospitals; andundertake parts of it (Bodenheimer, Wagner, third, most physicians do not receive adequateand Grumbach, part 2). The insurance- financial support from payers for coordinatingbased model of disease management tries to care (Landon, Gill, et al.).overcome the fragmentation of the market by Accountable care organizations—the subjecttaking a more patient-focused approach. The of another upcoming white paper—consist ofinsurers and third-party disease management hospitals and physicians that take collectivefirms rely on nurse care managers, who responsibility for the cost and quality of caretelephonically interact with patients to educate for all patients in their population. Whilethem about their condition and their health related in some respects to the original HMOrisks and work with them over time to effect concept, the ACO grew out of the ideasbehavior change. The major flaw in this model of Elliott Fisher, a professor at Dartmouthis that physicians are involved in the process Medical School, CMS Administrator Donaldonly peripherally. Berwick, and Commonwealth Fund PresidentMore promising models have emerged in the Karen Davis (Fisher, Berwick and Davis). It ispast few years. These include the patient- complementary to the PCMH in the sensecentered medical home (PCMH) and the that it could enable primary-care physiciansaccountable care organization (ACO). to benefit financially from improving careThe PCMH, which will be described in more coordination. Conversely, ACOs cannotdetail in a later white paper, is designed to function without a strong foundation of primaryhelp primary-care practices of all sizes provide care (Rittenhouse, Shortell, and Fisher).comprehensive primary care. Among its keycomponents are a personal physician who isresponsible for all of a patient’s ongoing care;team care; a whole person orientation; carecoordination facilitated by the use of health IT;a care planning process based on a robustpartnership between physicians and patients;and enhanced access to care, including non-PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 8
  9. 9. ACOs may be single business entities, such HMOs. In addition, information technology helpful in assessing and stratifying patientsas a group-model HMO or an integrated has advanced to the point where all patients and targeting interventions to the rightdelivery system. But they could also involve in a population can be identified, risk- people. The automation of the processesan “extended medical staff” or a contracting stratified, and provided with advanced self-network that includes a healthcare system. management tools to prevent exacerbationIPAs that have evolved into clinically integrated of their illnesses. Physicians didn’t haveorganizations could also serve as ACOs. these tools in the heyday of HMOs.While few ACOs exist today, the health reform David Lawrence, the former CEO of Kaiserlegislation encourages their formation by Permanente, points to another problem:allowing ACOs to share in savings they create the difficulty that primary-care physiciansfor Medicare, starting in 2012 (Kaiser Family would have in making the transition to theFoundation). Many healthcare organizations new delivery model. (While he cites thisare interested, because they foresee that future difficulty in regard to the medical home, thechanges in Medicare reimbursement may same criticism could be applied to ACOs,require hospitals and physicians to coordinate because primary-care physicians are thetheir efforts. linchpin of care coordination in both models.)The widespread development of ACOs, Lawrence believes that to increase accessperhaps with medical homes at their core, to primary care, we need to make use ofwould provide a powerful impetus for a shift “disruptive innovations,” including retailfrom the current care delivery model to PHM. clinics, employer-based wellness programs,With the backing of large organizations and home telemonitoring of patients with chronicthe introduction of financial incentives that conditions, and new methods of educatingencouraged an outcomes-oriented, patient- patients in self-management (Lawrence). With the backing ofcentered care model, PHM could become the To be able to manage all aspects of healthdominant model of healthcare. from wellness to complex care, healthcare large organizationsThe Crucial Role of Automation organizations must assess the entire and the introduction population, taking advantage of online orSome observers have raised serious web-based programs. Patients can then of financial incentives be stratified into various stages across theobjections to this rosy scenario. Consultantand healthcare expert Jeff Goldsmith, for spectrum of health. Those who are well that encouraged anexample, points out that the effort of insurance need to stay well by getting preventive tests outcomes-oriented,companies to pass financial risk to providers completed; those who have health risks needproved to be the Achilles heel of managed to change their health behaviors so they patient-centered care don’t develop the conditions they’re at riskcare in the 1990s (Goldsmith). This doesn’tnecessarily doom ACOs, however, because for; and those who have chronic conditions model, PHM couldthey will have to be accountable for quality as need to prevent further complications by become the dominantwell as for cost. This should prevent a public closing care gaps and also working onbacklash similar to the one that defeated health behaviors. Technology can be very model of healthcare.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 9
  10. 10. Technology is not a substitute for the physician-patient relationship,which is the basis of continuous care and can have a major, positiveeffect on health behavior.provides a more efficient and effective way to do appropriate IT tools can facilitate achievementpopulation health management. of all three goals while lessening the burden onWhat’s really needed for successful PHM is an practices.electronic infrastructure that performs much of One of the best ways to strengthen thethe routine, time- and labor-intensive work in doctor-patient relationship is to combine anthe background for physicians and their staffs. electronic registry with an automated method ofFortunately, most of the tools for building such communicating with patients who are overduean infrastructure already exist, although they for preventive and/or chronic care services.tend to be scattered and underused. When The patient demographic and clinical data inthese tools are pulled together and applied in the registry can come from billing systemsa coordinated, focused manner, they will be a or electronic health records, as well as labspowerful force for change. and pharmacies. The registry provides lists ofTechnology is not a substitute for the physician- patients with particular health conditions andpatient relationship, which is the basis of shows what has been done for them and when.continuous care and can have a major, positive By using evidence-based clinical protocols, theeffect on health behavior. But to the extent that registry can trigger outbound calls or secureautomation tools are used to strengthen that online messages to patients who need to makerelationship and enable physicians to provide an appointment with their doctor for particularvalue-added services that help patients improve services at specific intervals.their health, this technology can help drive Besides improving the health of the population,population health management (Lawrence). this automated messaging also brings patients back in touch with their physicians—in someThree Pillars of PHM cases, after long intervals of non-contact. Without requiring any effort from the doctors orTo do PHM properly, physicians and their care their staff, this combination of tools enhancesteams must strengthen their relationships with the doctor-patient relationship while alsopatients in a variety of ways, including making increasing practice revenues as a byproduct.sure that they come in for needed preventiveand chronic care. Care teams, which include Optimization of visits requires preparation byphysicians, midlevel practitioners, medical both the patient and the care team. The firstassistants, and nurse educators, must optimize thing patients should do is fill out a healththe services they provide to patients during risk assessment, either online or in the office,office visits. And they must extend their that shows the state of their health and whatreach beyond the four walls of their offices to they’re doing about it. The patients should alsoprovide a continuous healing relationship. The receive educational materials, including onlinePHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 10
  11. 11. multimedia tools, to prepare them for the office For a diabetic patient, a report related to thatvisit. condition would show the patient’s bloodwPhysicians and other care team members pressure and body-mass index, whether theyneed actionable reports that combine data had had an HbA1c test within a certain periodfrom their EHRs with data from registries, of time, and their HbA1c level, among otherother providers, and HRAs to show what has data points. If the reports were combinedbeen done for the patient and the gaps in their with the registry and the patient messagingcare that need to be filled. They also require software, the physician or midlevel practitionerreports that can help them figure out how to would be able find out whether and when theimprove the quality of care. While advanced patient had been contacted to come in for anEHRs include health maintenance alerts, they office visit or get a test done and whether theymay lack clinical dashboards that present key had made an appointment. In addition, themarkers of the patient’s status, may be unable care team can use these reports to reach outto compile data across a patient population to patients who need educational materials orto support quality improvement, and may be one-on-one educational sessions to learn howunsuited for patient care by a multidisciplinary to manage their conditions.What’s needed is a sophisticated rules engine that can incorporate disparate typesof data with evidence-based guidelines, generating reports that provide manydifferent views of the team (Fernandopulle and Neil Patel). Extending the reach of the care team beyondWhat’s needed is a sophisticated rules engine the office requires both the willingness ofthat can incorporate disparate types of data providers to stay in touch with the patientwith evidence-based guidelines, generating and modalities that help patients care forreports that provide many different views of themselves. Automation can help both sidesthe information. For example, the entire patient achieve those goals without excessive effort.population could be filtered by payer, activity For example, when a patient fills out an HRA,center, provider, health condition, and care they could receive educational materials tailoredgaps. The same filters could be applied to to their conditions and they could be directedpatients with a particular condition, such as to appropriate self-help programs for, say,diabetes, to find out where the practice needed smoking cessation or losing weight. And ifto improve its diabetes care. physicians had automated methods to contact patients and remind them of what they neededThe same approach could be used to produce to do to improve their health, they would bereports for care teams at the point of care. more likely to perform that component of PHM.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 11
  12. 12. ConclusionsTo create a sustainable healthcare system that provides affordable, high-qualityhealthcare to all, we will have to adopt a population health management approach.While the transition to PHM will be difficult for providers and patients alike, the changecould be facilitated and accelerated through the use of health information technology,self management tools, and automated reminders that are persistent in changingbehaviors.It will be several years before the majority of physicians and hospitals are using EHRs,and current EHRs lack many of the features required to improve population health. Butby combining EHRs with adjunctive technologies that already exist, physicians canrapidly move to PHM strategies that will benefit all of their patients and enhance thephysician-patient relationship.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 12
  13. 13. About the AuthorRichard Hodach, MD MPH PhDChief Medical OfficerDr. Richard Hodach is the Chief Medical Officer of Phytel. Dr. Hodach has long been recognized as an advocate ofintegrating IT with the practice of medicine. Before joining Phytel, Dr. Hodach, a board-certified neurologist, was the seniorvice president, chief medical officer at Matria Healthcare, where he provided strategic direction and clinical expertise inthe development of evidence-based, patient-centric population health products. He also has served as medical directorand vice president of Medical Affairs at Accordant, where he developed the medical concept and structure of Accordant’spatient-centric website and converted disease management programs into web-enabled disease management tools.He co-founded MED.I.A. (Media Interactive Applications), a company that designed, developed and produced medicalinteractive educational materials to be used by patients in their doctor’s office. Dr. Hodach has a PhD in Pathology and anMD with Board Certification in Neurology and Electrodiagnosis, as well as a Master’s Degree in Public Health.About PhytelPhytel creates consistent and sustainable patient engagement through automated coordinated care tools and services thatextend the reach of the physician beyond the office. This results in improved quality outcomes and increased profitability.Phytel’s outreach solution combines an electronic registry utilizing evidence-based protocols triggering outboundmessaging to patients who are in need of preventive and chronic disease care. By increasing compliance with physicians’treatment plans, our services substantially improve patient compliance with recommended care, leading to better patientoutcomes and assisting our clients in reaching their quality and financial goals.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 13
  14. 14. NotesAAFP, AAP, ACP, AOA, “Joint Principles of the Patient-Centered Medical Home,” February 2007, accessed at M. Berwick, Thomas W. Nolan and John Whittington, “The Triple Aim: Care, Health and Cost,” Health Affairs, May/June 2008, 759-769.Thomas Bodenheimer, Edeward H. Wagner, and Kevin Grumbach, “Improving Primary Care For Patients With Chronic Illness. JAMA.2002;288:1775-1779.Thomas Bodenheimer, Edward H. Wagner, and Kevin Grumbach, “Improving Primary Care For Patients With Chronic Illness: The Chronic CareModel, Part 2.” JAMA. 2002;288:1909-1914.Héctor Bueno, MD, PhD; Joseph S. Ross, MD, MHS; Yun Wang, PhD; Jersey Chen, MD, MPH; María T. Vidán, MD, PhD; Sharon-Lise T.Normand, PhD; Jeptha P. Curtis, MD; Elizabeth E. Drye, MD, SM; Judith H. Lichtman, PhD; Patricia S. Keenan, PhD; Mikhail Kosiborod, MD;Harlan M. Krumholz, MD, SM, “Trends in Length of Stay and Short-Term Outcomes Among Medicare Patients Hospitalized for Heart Failure,1993-2006. JAMA. 2010;303(21):2141-2147.Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Holmgren, M.P.A.,Jennifer L. Kriss, and Katherine K. Shea, “Mirror, Mirror On The Wall: An International Update on the Comparative Performance of American HealthCare,” The Commonwealth Fund, May 15, 2007, accessed at S. Fisher, Donald M. Berwick, and Karen Davis, “Achieving Healthcare Reform: How Physicians Can Help,” New England Journal ofMedicine 2009;360:2495-2497.Rushika Fernandopulle and Neil Patel, “How The Electronic Health Record Did Not Measure Up To The Demands of Our Medical Home Practice,”Health Affairs, April 2010, 622-628.Jeff Goldsmith, “The ACO: Not Ready For Prime Time,” Health Affairs Blog, Aug. 17, 2009, accessed at Family Foundation, “Summary of New Health Reform Law,” accessed at E. Landon, James M. Gill, Richard C. Antonelli, and Eugene C. Rich, “Prospects For Rebuilding Primary Care Using the Patient-CenteredMedical Home,” Health Affairs, May 2010, 827-834.David M. Lawrence, “How to Forge a High-Tech Marriage Between Primary Care and Population Health,” Health Affairs, May 2010, 1004-1009.David M. Lawrence, From Chaos to Care: The Promise of Team-Based Medicine. Cambridge, Mass.: Da Capo Press, 2003.Elizabeth A. McGlynn, Steven M. Asch, John Adams, Joan Keesey, Jennifer Hicks, Alison DeCristofaro, and Eve A. Kerr, “The Quality of HealthCare Delivered to Adults in the United States.” N Engl J Med 2003;348:2635-45.Paul A. Nutting, MD, MSPH, William L. Miller, MD, MA, Benjamin F. Crabtree, PhD, Carlos Roberto Jaen, MD, PhD, Elizabeth E. Stewart, PhD andKurt C. Stange, MD, PhD, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered MedicalHome.” Annals of Family Medicine 7: 254-260 (2009).Robert L. Phillips, Jr., and Andrew W. Bazemore, “Primary Care and Why It Matters For U.S. Health System Reform,” Health Affairs, May 2010,806-810.Institute of Medicine, Crossing The Quality Chasm. Washington, DC: National Academy Press, 2001.Diane R. Rittenhouse, Stephen M. Shortell, and Elliott S. Fisher, “Primary Care and Accountable Care — Two Essential Elements of Delivery-System Reform.” New England Journal of Medicine 2009;361:2301-2303.Meredith B. Rosenthal, Rushika Fernandopulle, HyunSook Ryu Song and Bruce Landon, “Paying for Quality: Providers’ Incentives for QualityImprovement,” Health Affairs, March/April 2004, 127-141.Gulshan Sharma, MD, MPH; Kathlyn E. Fletcher, MD, MA; Dong Zhang, PhD; Yong-Fang Kuo, PhD; Jean L. Freeman, PhD; James S. Goodwin,MD, “Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults.” JAMA. 2009;301(16):1671-1680.Ken Terry, Rx For Health Care Reform. Nashville: Vanderbilt University Press, 2007.PHYTEL | 11511 Luna Road | Suite 600 | Dallas, TX 75234 | Tel 800.559.3057 | ©2011 Phytel All rights reserved. 14