On February 17, 2009, I attended a meeting in Houston at which the concept of "medical home" was discussed. In the ensuing eight weeks, SETMA has been engaged in an examination of the concept of medical home and the issues related to it. In that time, we have completed a review of our entire practice based on the 28 requirements of medical home published by the Centers for Medicare and Medicaid Services (CMS). In that review, we have examined and adopted the following standards for evidenced-based medicine:
- Healthcare Effectiveness Data and Information Set (HEDIS) - published by he National Committee on Quality Assurance (NCQA) HEDIS measures are used by more than 90% of United States health plans to measure the effectiveness of care provided through their plans. HEDIS measures effectiveness of preventive care, acute care and chronic care based on the results of evident-based studies. In preparation for transforming SETMA into a Medical Home model of healthcare delivery, we have embedded the HEDIS data set into our electronic medical record. As a result, it is possible for a provider at the point-of-service to evaluate whether the elements of HEDIS have been met. In addition, that information will be reported to the patient in two ways. First, at the point-of-service, the patient will be given a document which will review their Medical Home Coordination information and status. This review will include all HEDIS measures which apply to that particular patient and it will tell the patient whether each measure has been met or not. It will also let the patient know what needs to be done in order to meet HEDIS standards. Second, quarterly, SETMA will publish on its website, a summary of the SETMA's providers' HEDIS performance. This will not identify patients nor individual providers, but will let patients know how SETMA as a team is doing. Internally, SETMA providers will be given their performance and that performance will be compared to other SETMA providers.
SETMA expects this function, and the introduction of the other four evidence-based standards of care into our EMR, to have a Hawthorne effect upon providers. What is that? There are three effects that observation and interaction has been shown to have upon people. The "placebo effect" is a well- known phenomenon that a patient's symptoms can be alleviated by an otherwise ineffective treatment, apparently because the individual expects or believes that it will work. The "Pygmalion effect" refers to self-fulfilling prophecy situations in which students performed better than other students simply because they were expected to do by their teachers. It is possible for others to benefit from both of these effects.
The "Hawthorne effect" addresses a change in behavior, usually positive, resulting from the knowledge that one is being studied. This effect was first observed in a series of experiments conduced from 1924 to 1933. The term "Hawthorne" was coined as the site for the experimental studies took place at Western Electric Hawthorne Work, Chicago. The publishing of he HEDIS data in our EMR, the making of it possible for a provider to measure their own work at the time and place of service, and the knowledge that the result of that work is going to be posted in a public place will change behavior.
- National Committee on Quality Assurance (NCQA) - Since its founding in 1990, NCQA has been at the forefront of advocating for improved healthcare delivery and providing standards to measure that improvement. The NCQA website makes the following comment:
"NCQA consistently raises the bar. Accredited health plans today face a rigorous set of more than 60 standards and must report on their performance in more than 40 areas in order to earn NCQA's seal of approval. And even more stringent standards are being developed today. These standards will promote the adoption of strategies that we believe will improve care, enhance service and reduce costs, such as paying providers based on performance, leveraging the Web to give consumers more information, disease management and physician-level measurement….
"...NCQA's programs and services reflect a straightforward formula for improvement: Measure. Analyze. Improve. Repeat. NCQA makes this process possible in health care by developing quality standards and performance measures for a broad range of health care entities. These measures and standards are the tools that organizations and individuals can use to identify opportunities for improvement. The annual reporting of performance against such measures has become a focal point for the media, consumers, and health plans, which use these results to set their improvement agendas for the following year."
SETMA is seeking NCQA recognition as a medical home and is also applying for NCQA recognition in diabetes care and in other clinic areas.
- National Quality Forum (NQF) - this forum has published almost 500 evidence-based measures which have been recognized as standards of care. About 120 of those measures apply to primary care. In order to quality for Medical Home recognition by the NCQA, a practice must report on eight of these measures. SETMA will report on 43 of these measures and each year will add others until we are reporting on all of those which apply to outpatient, ambulatory, primary care. Again, the results of this report will be published internally to our healthcare providers, will be reported to Golden Triangle Physician Alliance and Select Care of Texas, and will be posted on our website.
- Physician Consortium for Physician Performance Improvement (PCPPI) - also based on evidence-based medicine the Consortium data sets have been developed to allow healthcare providers to evaluate and improve their own performance at the point of care. Since their publication over the past five to ten years, SETMA has embedded many of the data sets into our EMR for diabetes, hypertension, weight management, congestive heart failure, asthma, chronic stable angina, etc.
- Physician Quality Reporting Initiative (PQRI) - first introduced in 2006 by CMS this evidence-based initiative defined 186 measures which could result in increased payments to providers and/or provider groups which reported on their performance of these measures and who exceed an 80% performance rate. The reporting is complex but due to our EMR, it is possible for SETMA providers to achieve this performance and reporting standard without interfering with patient care. There are 122 measures which apply to ambulatory, outpatient, primary care. To meet CMS standards, SETMA is required to report on 3 measures. Beginning in July, 2009, SETMA will report on 34 measures and each year will add others.
- Patient Centered Medical Home (PCMM) - recognition as a Tier III Patient Centered Medical Home by NCQA requires the fulfillment of more than 50 standards including communication, education, access, collaboration, evidence-based standards of care, planning, and review and reporting. SETMA is activity re-designing workflow and functionalities and implementing new capabilities to meet the highest level of NCQA standards. We expect to submit an application for Medical Home in September and will publish the results of that application process on our website.
- E-prescribing - it has long been a goal of quality-improvement in healthcare to make it possible for healthcare providers to submit prescriptions to pharmacies in an electronic format for safety, efficiency, convenience and excellence. Since January of this year, SETMA has been doing this. Patients and pharmacies like this service and it meets all of the standards of excellence which are required by CMS.
Teamwork
Yet, with these quality measures and functions as the foundation of the patient-centered Medical Home, the fundamental concept is built on the concept of a team. It is no longer the action of the super star but it is the collective and collaborative activity of the integrated team which will consistently and persistently achieve the results we all desire. Because of this, a provider's commitment to the content of evidence-based medicine can be emasculated by resistance to the organization, structure and dynamic of evidenced-based medicine! In healthcare, the standard is practicing evidence-based medicine, BUT - and here is the rub - evidenced based medicine does not only address the content of care but the organization, structure and dynamic of care. You may be committed to evidence-based medicine but resist the organization, structure and dynamic of the team approached with shared responsibilities which has been proved to produce superior result.
Medical Home does not succeed on the basis of one person's performance, or on the basis of the "leader's" performance - it succeeds on the basis of the TEAM's performance and the TEAM is the "organism" of evidence-based medicine." Marshall McLuhan said, "Our Age of Anxiety is in great part, the result of trying to do today's jobs with yesterday's tools." Paper and pen and Dictaphones are yesterday's tools for patient care. Electronic records are the tools of the 21st century. In the same way, the team is now the unit of evidenced-based medicine, not the individual physician. Michael Jordan said, "Talent wins games, but it takes teamwork and intelligence to win championships." This is why an excellent physician may never achieve the depth and breath of excellence he/she desires because of the absence of utilizing the power and resources of the team.
Too often the terms "group" and "team" are used interchangeably. This is unfortunate because there is a big difference between the two. A group is a unit of co-workers who perform their jobs in the same location but are not interconnected and functioning with the entire practice in mind. As a result, a group often experiences re-work and process inefficiencies. A team, on the other hand, not only functions with the entire practice in mind but also understands where their job fits into the whole. Team members who are given the option to participate in a problem-solving possess a greater sense of trust and feelings of mutual respect. A medical home needs to function like a well-oiled machine in order to deliver the care required by patients in the 21st century. Every member of the staff must recognize their contribution to the patient's experience and the value of the contribution.
2009 is a pivotal year in the history of SETMA. It will be interesting to report in 2010 how we have done in this radical transformation of our practice.
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