1. Evidence Based Medicine’s
Role in the Medical Home
2012 CMIO Leadership Forum
Donald R. Lurye, MD, MMM, CPE
Chief Executive Officer
Elmhurst Clinic, LLC
Elmhurst, IL
October 4, 2012

2. Elmhurst Clinic
Multi-specialty Chicago’s western suburbs since 1952
1996: Affiliation with Elmhurst Memorial Healthcare
2005: NextGenTM Ambulatory EHR
2007: Initiated hospitalist team at EMH
2009: Phytel RemindTM
2010: NCQA PCMH recognition
2012: Phytel InsightTM, RefillWizardTM
Today in 8 locations
Primary Care
45 IM/FM/Ped/OBG
11 Hospitalists
Specialty Care
42 Providers
19 Specialties

3. Ambulatory Care – The Challenge
• Historically a “cottage industry”
• Unmeasured
• Unmonitored
• Grounded in trusting relationships (still is)
• Standardized safety & quality relatively new
• Accountability very new
• Colored by traditional physician training culture
– Autonomy
– Heroism
– Evidence = a mix of science, belief & experience

4. What Is A Medical Home?
• “Marcus Welby on Steroids”
– D. Lurye, MD, Chicago Tribune, Oct. 27, 2010
• It Takes A Village, Not A Cottage
• Numerous Definitions
– NCQA
– AAFP/AOA/ACP/AAP
– AHRQ
– URAC
• Commonalities
– Physician directs a care team
– Comprehensive
– Coordinated
– Quality & safety measured and improved
– Enhanced access
– Communication

5. What Can A Medical Home Do?
http://www.pcpcc.net/files/benefits_of_implementing_the_primary_care_pcmh_0.pdf
• “Benefits of Implementing the Primary Care Patient-Centered
Medical Home” (examples from the PCPCC report)
– US Air Force: 77% of diabetics had improved glycemic control
– CO Medicaid: 96% CHIP participation; WCC up from 54% to 73%
– OH Humana Physicians: 22% fewer uncontrolled hypertensives
– Geisinger: 50% drop in readmits; many improved quality metrics
– Numerous examples of reduction in both utilization and cost
So how do we leverage evidence?

6. Evidence Based Medicine Defined
Ebell, M, et al., American Family Physician, Feb 1, 2004
• Strength of Recommendation Taxonomy (SORT)
– A: Consistent, good quality patient-oriented evidence
– B: Inconsistent, limited quality patient-oriented evidence
– C: Consensus, expert opinion, disease-oriented evidence
• Practice Guidelines
– Research driven
– Expert opinion
• Review Articles
• Meta-Analyses
• Internal Consensus

7. Access to Ambulatory Care
• Acute Care
• Prevention
– Primary
– Secondary
– Tertiary
• Traditional Elements of Access
– Extended & weekend hours
– Patient driven
• Access 2012
– Anticipatory
– EHR available 24/7
– Comprehensive prevention outreach
• Evidence based
• How to manage with ~70,000 patients?

8. Introducing Phytel RemindTM, OutreachTM
• Automated contact technology from Phytel
(www.phytel.com)
– RemindTM “reads” EHR, calls/emails app’t notification
– OutreachTM targets 2o & 3o prevention with evidence
• 46 Elmhurst Clinic physician approved care protocols
• Analyzes patient diagnosis lists
• Primary Prevention
» Adult & well child wellness exams (SORT C)
» Annual OBG visit (Expert opinion; moving target)
• Secondary Prevention - Diabetes
» Hgb A1C every 3-6 mos based on severity (SORT A)
» Lipid Profile at least annually (SORT A or B?)
• Tertiary Prevention
– Follow up on melanoma
– Follow up on bladder cancer
– So what’s happened at Elmhurst Clinic?

9. 12 Months Ending June 30, 2012
Category Description Quantity
Phytel
Messages Total Attempts 448,869
Phytel # App’ts Reminded 204,730
RemindTM # App’ts Successfully
Reminded 193,414
# Outreach Events 171,656
Phytel
OutreachTM # Patients Contacted 40,932
# Patients Contacted
Successfully 39,159
Total Unique Patients with a CPT Code Following Outreach 19,339
Outreach Return on Investment 13.18

10. Uptake of Phytel OutreachTM Appointments
Adherence Events CPT Codes
July 1, 2011 – June 30, 2012
5,000
4,500
4,000 y = -992ln(x) + 3095
3,500
3,000
2,500
2,000
1,500
1,000
500
0
15
25
35
45
55
65
75
85
95
5
105
115
125
135
145
155
165
175
Day from Outreach To Booking

11. McGlynn, E., et al., NEJM, 2003; 348:2636-2645
The Quality of Care Delivered to Adults in the
United States
• Surveyed 12 metropolitan areas
• Looked at 439 quality indicators in 30 acute &
chronic conditions and in preventive care
• Overall, 54.9% of recommended care delivered
– Acute, chronic & preventive interventions ~ equal
– High: cataracts (78.7%)
– Low: alcohol dependence (10.5%)
Why is this?

12. Embedding Evidence To Drive Quality
• In A Medical Home…
– Technology organizes evidence
– Non-physician staff implements a lot of the evidence
• Primary and secondary prevention
• Concept of the “Care Gap” (speaks to McGlynn article)
– Use physicians to exercise clinical judgment and
design interventions that work for each patient
We Have No Alternative To Process Change
Yarnall et al, Am J Pub Health, April, 2003, v. 94, no. 4
“To fully satisfy the USPSTF recommendations, 1,773
hours of a physician’s annual time, or 7.4 hours per
working day, is needed for the provision of preventive
services.”

13. Key Lessons – Common Chronic Diseases
• Physician challenges
– Multiple inputs all day, every day
– Patient’s issue of the day may be an acute problem
• Lost opportunity?
• Or a chance to maximize the value of the visit?
• EHR templates can drive recommended care
– Comprehensive
– Evidence based quality
– Communicate with other templates
• Much can be acted on by staff
– Increases physician focus
– Adds value to all parties

14. Sample Template – Chronic Disease Orders

15. Medication Refills
• A very complex issue at Elmhurst Clinic
– 120,000 per year
– Requests come in continually
– Can take 2-5 minutes each to decide if appropriate
– High expectations for response times
– 30 to 60 minutes per provider per day
• Many practices delegate refills
– “I know how my doctor handles this”
– Variation reigns
– Risks to quality and safety
– Staff licensure issues
– NOT an evidence based process
• No literature available to describe best practice
• Is there a better way?

16. A New Way to Leverage Patient Data
Internal Consensus Based Evidence
• What if physicians determined refill parameters?
• Timing of last visit
• Control of condition (diabetes, lipid, blood pressure,
allergies, etc.)
• Relevant lab results
– Values
– Timing
• All physicians agree on all protocols
– Reduces variation
– Reduces reliance on habit, assumptions
– Respects clinical staff licensure
• Protocols must be signed by physician(s)
• Protocol driven decision by RN only (meets IL law)

17. RefillWizard by healthfinch
• healthfinch protocols
– Used by founder, Dr. Lyle Berkowitz at Northwestern
– Adopted largely intact by Elmhurst Clinic
• Some modifications
• Collaborated on logical flow of product
• Added some drug categories
– Now in use by our internists, family physicians and
OBGYNs
• Results
– Up to 60% of refills (~72,000/yr) handled by RNs
– Consistency
– Efficiency
– Happier patients, happier doctors
– Life is better in a “top of license” practice!

18. RefillWizard – Refill By Nurse

19. RefillWizard – Refer to Prescriber

20. Population Based Care in a Medical Home
• Old Paradigm – “I will see you if you come.”
• New Paradigm – “I am responsible for you.”
• Do you know…
– Who among your hypertensives is controlled?
– Who among your females is due for a Pap smear?
– Who are your sickest diabetics?
– Who is most at risk if he/she misses a flu shot?
– Who hasn’t seen you at all in two or more years?
• Welcome to population health
– Impossible with patient-initiated care & paper charts
– A key component of a medical home

21. Phytel InsightTM
• Another look into the EHR
• Characterizes the population
– Who are really “our” patients?
– What are their significant conditions?
– How are we doing?
• Clinically meaningful measures
• Numerators
• Denominators
– Multiple data views
• Whole group
• Departments and/or locations
• Individual physicians

22. Case Management – Population View

23. Case Management – Care Gap View

24. Lessons Learned
• Evidence comes in many forms
• Evidence can make care better
• Practice transformation
– Is aided by technology
– Is informed by evidence
– Is driven by culture
• A medical home informed by evidence is health
care reform