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In Search of Technology that Improves Geriatric Care

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Using Checklists to Improve Primary Care for Seniors: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care system for Medicare patients, Oak Street Health, launched in September 2013. To read his prior posts about Oak Street Health, click here.]

Forgive me, I know it’s been a while. We’re now at 5 clinics, 2 more coming in the next few weeks, so I’ve been a bit distracted. That update another time. Here’s what I’ve been thinking about…

In a previous guest post, I blogged about building a foundation to collect data within the practice. Having data is nice. Of course, using it is better. As with my previous posts, we’ll use the Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” as our guide. Here is the third of the 10 recommendations.

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

First of all, I think it’s fair to say that my idea of clinical decision support is different from yours.My clinical training is in emergency medicine, and within that field there is a large and compelling body of evidence around decision rules. The Canadian Head and C-Spine CT Rules and Pulmonary Embolus Rule-out Criteria (PERC) are just a few of the most well known examples. These “rules” are all based upon large, multicenter trials, and are validated in later studies.

Where I trained at the Brigham & Womens’ Hospital in Boston, these rules were integrated into radiology order entry system. In other words, if I wanted to order a head CT, it had to meet those criteria…and I had to answer those questions in the computer.

It’s a nice way to build the evidence into the workflow, but it’s also pretty unrealistic to think that every primary care practice can build these tools into the EHR. And keep them up to date. And so on…

What about guidelines, such as those from CMS or the US Preventive Services Task Force? How are those coded in, and what if they change? And for everyone or just for the specific subpopulations to which they apply, say women between the ages of 65 and 75? What about which patients need an end-of-life plan documented?

Like I said: my idea of clinical decision support is probably different from yours. The simplest way I know of to manage through complexity is checklists.

How Oak Street Health Uses Checklists to Improve Primary Care

So we’ve developed a set of checklists for each step in the visit workflow, as well as over the life of the patient.

Here’s an example for how a Medical Assistant rooms a patient, complete with time-study data of how long that has been taking in our practice.

Inline image 2

And while we’d love to code answers to problems, we’re now fighting software with humans. Said differently, we’re actually adding scribes to the workflow as well. It’s hard for a physician to see a patient and manage a checklist…but if someone is in the room with you to remind you to go through the diabetes checklist for all diabetic patients?

And if we have a team to keep those checklists up to date and continuously improving? That might work, and it seems like it is…30% reduction in admissions thus far this year relative to the Cook County average?

We’re starting to call our scribes by a different term as a consequence of all these extra responsibilities. We call them “ninjas.”

So where technology can’t help us with decision support, maybe ninjas can?

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health in Chicago. You can contact him at griffin (at) oakstreethealth (dot) com.

Capturing Data to Improve Medicare Primary Care: The Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]
Forgive the brief hiatus: we’ve been busy with a growing
patient community and plans for taking our model to new neighborhoods.
We left
off last time with a discussion of infrastructure, and today we’ll transition
to what that infrastructure can do. Again from the Institute of Medicine report
“Best Care at Lower Cost: The Path to Continuously Learning Health Care inAmerica,” here is the next of the 10 recommendations.
Recommendation 2: The data utility. Streamline and revise
research regulations to improve care, promote the capture of clinical data, and
generate knowledge.
The most common source of data used in healthcare today is
claims data. This generally includes (1) patient indentifiers, (2) CPT codes
(i.e., billing codes), and (3) corresponding ICD codes (i.e., diagnoses to
justify the services billed). Together those create a matrix of who has what
medical conditions and the list of interactions with the healthcare system they
have to manage those conditions. 
These data are provided by payers and are
useful in understanding if a particular patient received a particular
intervention. For example, payers can tell which women aged 42 to 69 had a
mammogram during the previous 2 years. For us, that’s an important Medicare
metric that we can use to make sure patients get the right preventive services.
It’s a great start, but we want to go further.
At Oak Street, we have a hypothesis that structured,
clinically relevant, validated data has more predictive power than claims data
alone.(Think Lawton and Katz functional scores, PHQ-9 depression scores, etc.) So we work hard to create that data in each of
our interactions. We structure our charts so the data that goes in is usable.
(Think fewer text boxes, more numbers and drop-downs, etc.)
Deciding what to structure is nontrivial. Do you want
structured data for labs and vitals? Yes. How about medications and allergies?
We do. Timed-get-up-and-go scores? Probably. And bowel sounds? Probably not.The
ultimate goal of all of this is to make care much more systematic. We want to “triage”
patients so we know who needs the most attention now. We
want to flag errors and gaps: the system should tell us which patient needs a
colonoscopy…I don’t want to leave that to an individual.
Of course, this description feels like a technology project,
but it’s really more than that. It’s about training and creating a culture
where the whole team is proud of the data we create. That’s hard, and we work
on that every day.
As you can see, this “foundation” is no small task. Are we
perfect? Not close. But we did start with a focus on the digital infrastructure
to run a practice and utilizing data to do some creative things to take really
good care of older adults. The tools to do this will only get better with time,
and we hope our structured processes can fill in the gaps in the meantime.
Griffin Myers, M.D., M.B.A. is a founder and the Chief
Medical Officer at Oak Street Health in Chicago. He is currently in his final
year of an emergency medicine residency in Boston. You can contact him at
griffin (at) oakstreethealth (dot) com.
Disclosures

The author wishes to disclose a financial interest in the
primary care model discussed above. Furthermore, he is a trainee in a
postgraduate clinical training program, and neither the program nor the
affiliating university endorses, owns, or has any formal or informal
relationship with the primary care model.

Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

[Today’s guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, opened its doors in September 2013.]

Welcome back; this is the second in a series of guest posts I’ve been invited to write for GeriTech. As mentioned in my previous post, one nice way to think about our model of primary care for Medicare beneficiaries at Oak Street Health is using the list of recommendations put forth in the Institute of Medicine report “Best Care at Lower Cost.”

This post is about the first recommendation, which falls into what the report groups into the category of “Foundational Elements.” Ironically we’ve found these to be the hardest objectives thus far. We’re still in a bit of flux as we get settled into our new setup, but I’ll give an introduction.

“Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.”

This immediately brings to mind a super-EHR: one product for charting, practice management, financials, claims, population health, and clinical decision support.

But, surprise: there is no off-the-shelf product that integrates all of this for primary care, never mind primary care for seniors. At least not that we’ve found after an extensive search. There are products for each of those functions, but not a single package. And asking providers to use multiple non-integrated products isn’t a real solution. Here’s our approach.

How we chose an EHR & practice management system [Read more…] about Digital Infrastructure for Medicare Primary Care: the Oak Street Health Story

How to Develop Better Primary Care for Seniors

[Extra-special treat today! This clinician guest post is by Dr. Griffin Myers, whose innovative primary care clinic for Medicare patients, Oak Street Health, just opened its doors this month in Chicago.]

Nationwide seniors are up against a wall when it comes to primary care, and this is particularly true in Chicago, home of our new approach to integrated geriatrics care called Oak Street Health. We recognized the need and are now on a journey to fix it.

In 2012, I (an emergency medicine resident) and two colleagues (an attorney and a financial engineer) launched what we believe is a truly innovative approach to caring for seniors. Your blog host, Dr. Leslie Kernisan, has been an email-mentor to me through this process and has now invited me to be a guest blogger on GeriTech. Over the coming weeks and months, I have the honor of blogging to you about what we’ve built, how, why, and what’s coming next for us in our mission to build the right kind of care model for seniors. I hope you enjoy the posts, and please: feedback and suggestions are welcome. We’re a humble bunch, and we hope to learn from these conversations as well.

Chicago is a city of over 1 million seniors. The primary care infrastructure is anecdotally thin: patients tell us appointments require weeks of notice, wait times are long, and many doctors aren’t taking new patients. Furthermore, most primary care providers are either (a) employed by a large hospital system or (b) a part of a large multi-specialty practice; from an economic standpoint, this means primary care exists not for its own sake but instead to serve as an aggregator for referrals to more highly reimbursed specialty services.

The typical Medical patient in Chicago has an unfortunate burden of disease:

  • 24% have diabetes
  • 17% have CHF
  • 12% with depression
  • 11% with COPD
  • 9% with CKD
  • 6% with cancer

Beyond the disease burden, the complexity of the care ecosystem is onerous; the typical Medicare patient in Chicago must manage the following:

  • He/she takes 11 medications a day, from 5 drug classes, prescribed by 2-3 providers, dispensed from 1-2 pharmacies.
  • He/she sees 7 physicians in a year, which includes 2 primary care providers, all across 4 different practice locations.

Furthermore, that same patient is not well equipped to manage his/her disease:

  • 73 years-old
  • 56% with high school diploma or less
  • 45% below twice the poverty level
  • 30% with a functional limitation

And it’s not just patients who face challenges; primary care providers have a daunting task as well:

  • Too much to know: there were roughly 900,000 medical journal articles published last year.
  • Too much to do: following recognized society guidelines would require 21.7 hours/day for a practicing primary care provider, excluding documentation (and eating, sleeping, etc.).
  • Too much to manage: there are 87 different categories of United States Preventive Services Task Force recommendations for management of preventive/maintenance care.
  • Too much to coordinate: a typical primary care provider in Chicago has a panel of 2,000-2,500 patients and must work with 299 other physicians across 117 practices over the course of the year to manage that care.

In our population in Chicago, a typical hospital admission costs $10,000. The reimbursement for CPT 99212, a medium complexity visit with an establish patiented, is $43.89. That means you can buy 228 clinic appointments if you avoid one hospitalization. (Just for comparison, there are around 250 business days in a year.)

How does all this add up for us? We’ve tried to build two things: (1) a primary care model that creates downstream savings in acute care and (2) an economic model that lets us capture the savings we create and reinvest them in even better primary care. One of the many tools we’re considered in developing the Oak Street Health model was the recent Institute of Medicine report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report contains 10 recommendations in 3 broad categories for how to achieve “best care:”

Foundational Elements

Recommendation 1: The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.

Recommendation 2: The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Care Improvement Targets

Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.

Recommendation 5: Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

Recommendation 6: Care continuity. Improve coordination and communication within and across organizations.

Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.

Supportive Policy Environment

Recommendation 8: Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.

Recommendation 9: Performance transparency. Increase transparency on health care system performance.

Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.

Easier said than done, but over the coming posts, I’ll use this framework to explain our philosophy and our approach to what we think matters in achieving “best care.” Up first? Recommendations 1-2.

Until then, take a look at WGN’s coverage of the opening of our first center in Chicago’s Edgewater neighborhood, and please post any questions or suggestions for us in the comments!

Griffin Myers, M.D., M.B.A. is a founder and the Chief Medical Officer at Oak Street Health. He is currently in his final year as an emergency medicine resident in Boston. You can contact him at griffin (at) oakstreethealth (dot) com.

 

Disclosures: Dr. Myers wishes to disclose a financial interest in the primary care model discussed above. Furthermore, he is a trainee in a postgraduate clinical training program, and neither the program nor the affiliating university endorses, owns, or has any formal or informal relationship with the primary care model.

 

References & Links

–    U.S. Census Bureau

Centers for Medicare and Medicaid Services.

Schneider K, O’Donnell BE, Dean D, Prevalence of multiple chronic conditions in the United States Medicare population, Healthand Quality of Life Outcomes 2009, 7:82.

Choudhry NK, Fischer MA, Avorn J, Liberman JN,Schneeweiss S, Pakes J, Brennan TA, Shrank WH. The implications of therapeuticcomplexity on adherence to cardiovascular medications. Arch Intern Med. 2011May 9;171(9):814-22.

Lee TH, Mongan JM. Chaos and Organization inHealth Care, MIT Press, 2009.

Pham HH, Schrag D, O’Malley AS, Wu B, Bach PB.Care patterns in Medicare and their implications for pay for performance. NEngl J Med. 2007 Mar 15;356(11):1130-9.

National Research Council. Best Care at LowerCost: The Path to Continuously Learning Health Care in America. Washington, DC:The National Academies Press, 2012.

U.S. Preventive Services Task Force Recommendations for Adults

Pham, H. H., A. S. O’Malley, P. B. Bach, C.Saiontz-Martinez, and D. Schrag. 2009. Primary care physicians’ links to otherphysicians through Medicare patients: The scope of care coordination. Annals of Internal Medicine 150(4):236-242.

Oak Street Health analysis