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Learning Health Care Systems
Learning Health Care Systems Engines of Success for U.S. Health Reform? Grand Rounds I Beth Israel Deaconess Medical Center I January 24, 2013Eric B. Larson, MD, MPHVice President for Research, Group HealthExecutive Director, Group Health Research Institute
Why this topic? Why today? 1999 2001 The IOM planted the idea of “learning health care systems” more than a decade ago to solve the quality crisis.
More than a decade later…We are still struggling to achieve “the triple aim”: • Improving patient experience (quality & satisfaction) • Improving the health of populations (better access) • Reducing per capita cost
Berwick & Hackbarth on the problem:Eliminate systemic waste (JAMA 2012)Total U.S. health care system waste = $11 trillion over nineyears“The savings potentially achievable from systemic,comprehensive, and cooperative pursuit of even a fractionalreduction in waste are far higher than from more direct andblunter cuts in care and coverage.” 4
A matter of professional ethicsTo make a difference, we must address all categories at once:• Overtreatment• Failures to coordinate care• Failures in care delivery• Excess administrative costs• Excessive health care prices• Fraud and abuseAddressing waste is a matter of professional ethics.Waste must be addressed by professionals from within the system.
Estimated annual waste by categorySingle-year (2011) estimates based on a review of the wasteliterature, after resolving overlapping areas: 6
What can be done?Today’s system appears wedded to prevailing paymentarrangements.Powerful forces have a strong stake in preserving the status quo.(“It works for us.”)Must we accept poor quality, lack of access, higher costs?Some doubt the U.S. health care system can change itself: • Stanford economist Victor Fuchs in The New York Times: The only solution may be change that profoundly “unsettles established interests.” • He quotes Alexis de Tocqueville: In the U.S., “events can move from the impossible to the inevitable without ever stopping at the probable.”
Can learning health care systemsbe the engines of change? Overview of today’s talk: • History and development of a learning health care system (LHCS): Group Health Cooperative • Potential opportunities for research in LHCS • What we’ve learned about LHCS: Challenges & rewards • How LHCS can help solve the crises in quality, access, cost
The challenges. The opportunity.The IOM’s 2008 Roundtable on Evidence-Based Medicineidentified problems with U.S. health care:• Evidence is often not available for clinical decision making.• Uptake of new discoveries can be slow and false starts are common.• Even when evidence is available, it is not applied consistently—meaning variation, inefficiencies, and disparities persist.Opportunity:• We need a new clinical research paradigm.• We need “learning health care systems.”
The challenges. The opportunity.In learning health care systems, traditional principles of researchcan be used in more practical ways so that:• Decisions can be made more quickly.• Better information is available for clinical decision making, for managing health care delivery.
What is a learning health care system? The IOM’s vision: • Research happens closer to clinical practice than in traditional university settings. • Scientists, clinicians, and administrators work together. • Studies occur in everyday practice settings. • Electronic medical records are linked and mined for research. • Recognition that clinical and health system data exist for the public good. Evidence informs practice and practice informs evidence.
One example: Group Health CooperativeFounded in 1947 “To Serve the Greatest Number”
Today’s Group HealthA Seattle-based health plan serving 620,000 in Washington, IdahoCombines health care and coverage1,200 physicians and 9,500 staffNearly 2/3 of members get care at Group Health facilitiesAnnual revenue: about $3.3 billionIncludes Group Health Research Institute
Today at Group Health Research Institute Non-proprietary, public interest About 300 employees working on more than 250 concurrent studies 39 scientific investigators, including MDs, epidemiologists, biostatisticians, health services researchers, psychologists 33 affiliate investigators (mostly UW, Group Health medical staff) More than 300 publications in peer- reviewed journals each year Grant dollars in 2012: $46.3 million
Primary areas of research focus Biostatistics Cancer Prevention & Control Women’s Health Chronic Improved health & Illness Care Health Systems health care through Organization & research, innovation & dissemination Immunization Finance Preventive Care & Mental Health and Health Promotion Behavioral Medicine
Research is in Group Health’s DNA1947: Group Health’s original mission statement: “Contribute tomedical research”1950s-60s: University-based researchers mine Group Health databeginning in 1956 with the Seattle Longitudinal Study on Aging1970s: Group Health’s own research on its preventive care servicesbegan1983: Group Health Research Institute (GHRI) founded withEd Wagner, MD, MPH, as director
Research is in Group Health’s DNA1980s:• NCI funds phone-based tobacco cessation research, leading to changes in coverage, successful quit lines nationwide• Bike helmet studies show link to reduced head injuries, leading to bike helmet laws and wide-spread use1990s:• Chlamydia screening proven effective against PID; CDC recommends Chlamydia screening• Collaborative care proven effective for depressionEarly 2000s:• Alternative care can help back pain• Improved diabetes care reduces cost
Highlights of GHRI’s first 25 yearsRegistries for breast cancer screening and immunization • 1987: The nation’s first breast cancer screening registry and reminder system • 1988: 1 of 5 sites in the CDC’s first Vaccine Safety Datalink • JAMA 1995: 32% reduction in late-stage breast cancer and 89% of 2-year- olds have complete immunizations • Both registries enable ongoing large-scale research that impacts clinical recommendations and national standardsThe Chronic Care Model • Developed at GHRI’s MacColl Center for Health Care Innovation as a way to improve diabetes care and outcomes • Now used worldwide for diabetes, depression, congestive heart failure, asthma, and other chronic conditions
Challenge: Linking researchto practice and vice versa2002 “Access Initiative”• Group Health has always been primary-care based; aspired to be patient-centered.• Reputation and past performance in “managed care” and as a traditional HMO: Access was a problem.Access Initiative elements included:• Same-day appointments• Open access to specialists• A new EMR with secure website for members• Ambitious productivity standards• Reimbursement change
Challenge: Linking researchto practice and vice versaUniversity of Washington/Group Health study of “AccessInitiative” showed: • Increased patient satisfaction • Markedly improved access and productivity • But no gains in clinical quality, and • A dramatic negative impact on primary care provider work lifeNext step: • Patient-centered medical home pilot • Can it improve quality and revitalize primary care? • Our design benefitted from “lessons learned” through the Access Initiative
Patient-centered medical home torevitalize primary careGenesis of medical home concept: Special-needs pediatricsand internal medicineReinvigorated core attributes of primary careMore system support for chronic illness careAdvanced information technologies (EMR, registries,reminders, patient portals)Supportive physician payment methods (promotes medicalhome goals, not simply volume)
Patient centered medical home torevitalize primary careDesign principles for Group Health’s pilot: • Panel size reduced from 2,300 to 1,800 patients • Appointment times increased from 20 to 30 minutes • Expanded multi-disciplinary clinical teams • Desktop time for physicians • E-technology and communication (EMR and secure e-mail with patients)
2-year evaluation shows positive resultsReid RJ et al, Health Affairs 2010;29(5):835-43Larson EB et al, JAMA 2010; 306(16):1644-45Reid RJ et al, Am J Manag Care 2009;15(9):e71-87
Patient experience in the medical home Significantly higher scores for patients at pilot clinic Year Year 1 2 Quality of patient-doctor interactions Shared decision making Coordination of care Access Helpfulness of office staff Patient activation/involvement Goal setting/tailoring Compared to Medical Home Medical Home Difference not controls: higher lower significant
Staff experience in the medical home Marked improvement in burnout levels at prototype clinic at 1 year Medical Home Control Clinics Emotional Exhaustion Baseline 44.4% 54.2% 12 month 19.4% ** 54.5% Depersonalization Baseline 25.0% 25.0% 12 month 18.8% 30.4% Lack of Personal Accomplishment Baseline 25.0% 18.2% 12 month 10.0% 25.6% -60% -40% -20% 0% 20% 40% 60% ** p<0.01 % Patient Care Employees rating as "Moderate/High"
Utilization & costs in medical homeYear 1: • 29% fewer ER visits • 11% fewer preventable hospitalizations • 6% fewer but longer in-person visits • No significant difference in total costs between medical home and control clinicsYear 2: • Significant utilization changes persisted • Overall patient care costs lower at medical home (~$10 PMPM)
Lessons learned from Group Health’spatient-centered medical home pilotPatient-centered care saves costs by lowering inappropriate useof emergency care and avoiding preventable hospitalizations.Investment can achieve relatively rapid returns across a range ofkey outcomes, even in an already integrated system.The evaluation provides some of the first empirical evidence ofthe benefits of the medical home.The evaluation gave leadership the confidence to invest $40M inredesign of primary care, spreading the medical home to all 26 ofits medical centers.The evaluation served as a model for our evolving learninghealth care system.
Group Health’s concept ofa learning health care system (LHCS)
Unwarranted variations in surgical careare pervasive in the U.S. The Dartmouth Atlas Project has found widespread geographical variation nationwide in the use of elective surgical procedures. Patients in Wenatchee, WA are three times more likely to have their arthritic knees replaced than are similar patients in Honolulu. Men in Bellevue, WA are much less likely than those in Thousand Oaks, CA to undergo surgery for benign prostate disease. This variation reflects physician training and preference—not what patients want or need.
More LHCS projects have followedExample: Shared decision making2007: Washington State passes nation’s first law endorsingshared decision making (SDM)SDM provides shelter from liabilityState mandates demonstration projects, leading SDM research atGroup Health.
More LHCS projects have followedExample: Shared decision makingIn 2009, Group Health launched a system-wide shared decisionmaking initiative12 video-based decision aids in six specialty services: • Orthopedic: hip and knee osteoarthritis • Cardiac: coronary heart disease • Urology: benign prostatic hyperplasia and prostate cancer • Women’s health: uterine fibroids and abnormal uterine bleeding • Breast cancer programs: early-stage breast cancer, breast reconstruction, and ductal carcinoma in situ • Back care programs: low back pain from spinal stenosis and herniated disc
SDM is not new to Group Health,but translating findings isGroup Health published studies on the value of SDM for BPH and lowback pain the mid-1990s. Results: High patient satisfaction, lower cost.But we lacked mechanisms to move such findings into practice. Wagner EH et al, Med Care 1995;33(8):765-70
SDM conclusions to dateLarge scale implementation of patient decision aids is feasibleUse of decision aids for SDM appears to be one way to achieve the“triple aim” in health careImproves patient satisfaction (& knowledge)Appears to lower rates of elective surgeryReduces costs or is at least cost-neutralIs generally well-accepted by providersOffers potential for greater liability protection
Preliminary findings in women’shealth and urology Treated Untreated Prostate AUB/ BPH BPH Cancer Fibroids Impact on Impact on surgery use surgery use Impact on Impact on health care health care costs costs Unpublished findings
LHCS example: Reducing harmsfrom advanced medical imagingGroup Health study shows wide variation in radiation exposure fromcomputed tomography (CT) scans and increased use over time. Smith-Bindman R et al, JAMA 2012;307(22):2400-9
LHCS example: Reducing harmsfrom advanced medical imagingEstimated that CT-induced cancers could be reduced by 40% if thehighest 25% of radiation doses from pediatric CT could be lowered tothe median dose.Based on these results, Group Health began developing ways tolower radiation exposure from medical imaging.Researchers and the radiology service collaborated to provide CTtechnologists with feedback reports, training on CT doses.The technologists are eager for more education and want to engageradiologists in discussions about developing dose monitoringprotocols.Researchers will evaluate whether dose-feedback reports and dose-reduction education reduce radiation exposure for Group Healthpatients.
LHCS example: Addressing risks of chronic opioid therapy An epidemic of prescription opioid abuse Group Health Research Institute: Higher opioid dose linked to prescription opioid 16000 overdose risk in chronic pain cocaine patients (Annals of Internal 14000 heroin Medicine, 2010) 12000Number of deaths Washington State guideline: 10000 Safe opioid prescribing requires 8000 clinical evaluation, treatment agreements, periodic monitoring, 6000 urine drug screening, and medical records treatment 4000 documentation 2000 Federal Action Plan: 0 Epidemic—Responding to 99 00 01 02 03 04 05 06 America’s Prescription Drug Abuse Crisis (Office of National Year Drug Control Policy, April 2011)
LHCS example: Addressing risks ofchronic opioid therapyGroup Health launches a comprehensive opioid prescribingsafety initiative in 2010.• Objectives: standardized practices, clarification of treatment goals and expectations, fewer cases of abuse, misuse, and overdose• Standardized care plans: one responsible prescribing physician, refill planning and monitoring, urine drug screening for high-risk patients, referral guidelines• Training: Web-based CME on how to implement the standardized care plans, funded by the Group Health FoundationThe initiative produced stunning results that outpaced the federalcall to action (April 2011)….
LHCS example: Addressing risks ofchronic opioid therapy Cumulative By May 2011, 85% of Group Health chronic opioid therapy patients had documented care plans. 7,000 6,000 5,000 No. care plansper month 4,000 3,000 2,000 Note: Chronic opioid therapy defined as having filled at least 5 prescriptions in the past 90 days or 1,000 taking opioids for at least 90 days in a pattern or quantity that indicates daily or near-daily use. 0 06/01/10 07/01/10 08/01/10 09/01/10 10/01/10 11/01/10 12/01/10 01/01/11 02/01/11 03/01/11 04/01/11 05/01/11 Month Cumulative Today, COT care plans at Group Health are nearly universal.
Partnership for Innovation:An opportunity to pilot clinical staff’s ideas Group Health Group Health care-delivery system Research Institute • 1,200 physicians • Non-proprietary, public • Patient-centered care interest science • Aligned incentives to innovate • Focus on practical research for better care Group Health Partnership for Innovation • Ideas come from Group Health staff • Funded by Group Health Foundation • Group Health Research Institute helps design & evaluate
Partnership for InnovationGrantee selection criteria• Will it promote better care at a lower cost?• Is it a new process, product, or service?• Is it an incremental change?• Is it patient centered?• Is it feasible?• Does leadership support the work?Some examples…
Pediatric intranasal flu vaccineTotal funding: $75,532InnovationProvide painless flu-vaccine optionfor childrenPotential benefits • Increase flu vaccination rates • Increased patient/family satisfactionResults • Parents perceived intranasal vaccine as risky • Uptake was lower than expected • Intranasal vaccine program dropped
Outpatient orthopedic ultrasoundTotal funding: $34,897InnovationDiagnosing shoulder injuries inoutpatient setting with portableultrasound devicePotential Benefits• Less use of high-end imaging• Higher patient satisfactionResults• Demonstrated reduction in MRI usage• 200 percent return on investment• Will expand system-wide
Learning health care systems can addressthe BIG questions for U.S. health careWhat’s the best use of limited resources?What works? What doesnt?How can we cut out waste, inefficiencies, errors?How can we leverage the strengths of integrated care systems?How can we address the problems of an aging population?How can we address growing burdens of chronic illness?How can we contain costs so we can afford to care for theexpanded number of people who will soon have coverage?
What we have learned in developing aLHCS at Group HealthWe can learn more quickly, produce more timely results.Research can align with the care-delivery system’s business goals.We always strive for projects that are: • Generalizable • Public-domain • Leading to nationally relevant discoveries and solutionsFunding these projects can be challenging, but not impossible.
What does the future hold for LHCS?New sources of support:Patient Centered Outcomes Research Institute • Founded in 2010 under the Affordable Care Act • Nonprofit, nonfederal, independent • Patient and stakeholder input influences all phases • Patients and stakeholders are reviewers • Budget: $3 billion for 2012-2019
What does the future hold for LHCS?New sources of support:Health Care Systems Collaboratory • Established by NIH Director Francis Collins, MD, PhD, through the Common Fund • Engaging health systems in large clinical studies • Coordinating Center at Duke University funded in 2012 • $11.3M for first year • Includes HMO Research Network (19 integrated health plans) • Recently funded seven “pragmatic trials” to develop and spread best practices—includes studies of suicide prevention, colorectal cancer screening, and care for low back pain
What does the future hold for LHCS?New opportunities through large, multi-site studies:Example: The Mini-Sentinel • Funded by the FDA• Active, extensive surveillance system to monitor the safety of regulated medical products• Gathers data from 29 health care organizations nationwide
ConclusionThe potential is rich.Can Victor Fuchs’ assessment be right? Will change only comethrough an unraveling of the current system?Or can we make our learning health care systems the engines ofsuccess for U.S. health reform?Let’s take this as a matter of professional ethics, exercisingprofessional obligations to our patients.Let’s drive the change, achieving de Tocqueville’s prediction ofinevitable and positive change.