The Virtual Connection: Electronic Visits Joseph E. Scherger, MD, MPH National Medical Home Summit March 3, 2009
The Holy Grail of Health Care 2009 Cost Reduction Quality Improvement Service Improvement
The Secret Sauce for Success Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Patients become activated for self- management
NCQA Recognition as a PCMH Access and Communication Patient Tracking and Registry Functions Care Management Patient Self-Management Support Electronic Prescribing Test and Referral Tracking Performance Reporting and Improvement Advanced Electronic Communications
58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and back pain. She has a 15 minute appointment HEDIS diabetes measures for this patient: Percent with an annual retinal exam Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests showing a level of <8.5 percent (goal <7.0) Percent with an annual screening test for microalbuminuria Percent with two or more blood pressure checks per year Percent of those with one or more blood pressure checks having a systolic BP <135 (goal <<130/80) Percent with an annual lipid panel Percent of those with an annual lipid panel showing an LDL level <130 mg/dl (goal << 100)
Case con t Other Diabetes Measures: Flu vax Pneumovax Dental visit Cardiac screening test? Lab monitoring for side effects of meds Annual foot exam Baseline EKG?
Case con t Cancer Screening needs: Colon- needs colonoscopy (or 3 other types of screening) Cervical- needs pap if last <1-3 3 years prior Breast- needs annual mammogram Osteoporosis screening and prevention Depression Screening and Management
Case con t General health issues: Adult Td Weight management Advance Directives/DPOA Culturally-sensitive care Patient Education Self Management Tobacco Screen Alcohol screen Domestic violence screen
The Time Problem Time Needed for Chronic Illness Care Time Needed for Preventive Care Time Needed for Acute Care Total face to face time for 2500 patients 10.6 hours a day for 2500 patients 7.4 hours a day 4.6 hours a day 22.6 hours/day Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635
The Ticking Clock in the Doctor s s Office: Patients on routine visits to their primary doctors often have lots of questions but not enough time to get good answers NY Times Feb. 6, 2007
Communication Digital Connection of Patients with Caregivers Information Technology Changing Medicine Knowledge Management and Decision Support Tools Patient Information EHR, All Clinical Data
The First Rule of Redesign Crossing the Quality Chasm New Model of Medical Practice Care is Based on Continuous Healing Relationships Patient Centered Medical Home
Health Care Becomes Continuous Patients Live Their Health and Illnesses Every Day Quality Health Care Offers Continuous Access and Engagement Patients Will Drive the Innovation Patients Will Have Their Medical Records Patients Have Access to All Medical Information The Return of the Public Library Patients Will Communicate Far and Wide for Care
Young Can t t Imagine Life Without Online Access Associated Press December 5, 2004
Why Use E-Visits? E Improve patient access Enhance patient education Increase patient satisfaction Reduce telephone time and costs Can balance risks and benefits Competitive advantage Transform work schedule
Benefits of E-MailE Visit extender - increased communication Patients forget questions Intimidated face-to to-face Enhance participatory relationship Change service utilization Behavioral coaching
Potential Problems with E-MailE Confidentiality and security Time demands Misinterpretation Inappropriate uses Digital divide
Myths About Patient E-MailE Myth #1: Hackers could read my patient s s confidential messages. Myth #2: It will take more time from my day, and I won t t get reimbursed for it. Myth #3: If I allow patients to e-mail e me, I will receive a flood of e-mail e messages. Myth #4: Patients will ramble. Myth #5: I may get sued, and a lawyer will discover my e-mail e messages.
The New Communication Interactive Web Site For: Lab Results And Other Data Arranging Preventive Services Chronic Illness Care Behavioral Coaching Group Visits Minor Acute Problems
LDL Management May Be Easier With E-MailE Family Practice News, July 1, 2004 William T. Lester Randomized Trial at Mass Gen Hosp Better Management Fewer Visits
The Doctor Is Online Simply providing a surgeon s s e-mail e address nearly triples the likelihood that a patient will contact the doctor about the surgery New York Times, Feb. 18, 2008
RelayHealth study California study with Blue Cross of California Controlled trial with 5727 patients Physicians reimbursed $25 per visits with patients having a $0-10 co pay Results: Overall decrease in spending of $1.92 per patient per month for office visits, $3.69 overall Improved patient satisfaction
Time spent on patient email is predictable Average Emails per patient per week 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 No. of Weeks Since 1st Office Visit 1000 pts @ 5 min/email 8 hrs/week/1000 pts 1000 pts @ 10 min/email 16 hrs/week/1000 pts
Old Schedule First patient at 8 am and 12 patients each half day session 24 patient visits 12 patient phone calls Done at 6:30 PM Patients served -- 36
New Schedule Begin e-mail e at 8 am and communicate with 15-20 patients. First patient at 9:30. 6 patients/session 12 Patient Visits vary in length from brief to extended 4 patient phone calls 34 patient e-mails e in 2 sessions lasting 30-45 min. each Done at 5:30 PM Patients served -- 50
A New Model of Office Practice 50% More Caring Interactions Each Day 10-12 12 Unhurried Office Visits Each Day Advanced Access Do Today s s Work Today Patients Get All the Time They Need Patients Receive the Excellent Care
How? An Interactive Practice Website 40-60% of Patient Needs Handled Online or by Telephone Electronic Health Records with Imbedded Knowledge Management Tools Great service
Concierge Care for Everyone? Fewer Patients per Family Physician Continuous Availability Focus on Comprehensive Care Including Prevention Enhanced Professional and Patient Satisfaction Is Concierge Practice the Custom Invention that will lead to the Model of the Future? American Society of Concierge Physicians is now the Society for Innovative Medical Practice Design Make it Affordable
Greenfield Health 9 FPs and IMs Practice in Portland, OR, 2 offices Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Physician Spends Half Day Seeing Patients Visits 30 Minutes or Longer Half Day Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Annual fees range from $195 to $495 depending on age
Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services
Dr. Christy Calderon, a family physician at Kaiser Permanente s Whittier office, conducts as many as half her appointments over the phone or online with a 3 inch camera affixed to her desktop. Los Angeles Times, Feb. 4, 2008
Financial Models for the New Model Shift of telephone to E-mail E (time saver, $ neutral) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Payment for virtual care (Web Visit Charges) Prepaid service fee, monthly ($30) or annual ($360) Prepaid Contracts Pay for Performance incentives Billing for Group Visits
Finances Follow Innovation The New Model is More Efficient Better Faster Cheaper!
The Secret Sauce for Success Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Patients become activated for self- management
Relationship Centered Care What is the 21 st Century Application?
Wise Words from Dee Hock Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference.
Change Is Disturbing When It Is Done To Us. Change Is Exhilarating When It Is Done By Us Rosabeth Kantor Harvard Business School
Human Nature Changes Little Caring Remains Primary What Changes Are The Tools And Methods We Use