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The Virtual Connection: Electronic Visits

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.

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The Virtual Connection: Electronic Visits

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  1. The Virtual Connection: Electronic Visits Joseph E. Scherger, MD, MPH National Medical Home Summit March 3, 2009

  2. The Holy Grail of Health Care 2009 • Cost Reduction • Quality Improvement • Service Improvement

  3. The Secret Sauce for Success • Care becomes continuous access rather than episodic • Care becomes proactive rather than reactive • Patients become activated for self-management

  4. 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

  5. 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)

  6. 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?

  7. Case con’t Cancer Screening needs: • Colon- needs colonoscopy (or 3 other types of screening) • Cervical- needs pap if last <1-3 years prior • Breast- needs annual mammogram Osteoporosis screening and prevention Depression Screening and Management

  8. 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

  9. Time Needed for Chronic Illness Care Time Needed for Preventive Care Time Needed for Acute Care Total face to face time for 2500 patients Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635 10.6 hours a day for 2500 patients 7.4 hours a day 4.6 hours a day 22.6 hours/day The Time Problem

  10. The Ticking Clock in the Doctor’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

  11. Information Technology Changing Medicine Knowledge Managementand Decision Support Tools Patient InformationEHR , All Clinical Data CommunicationDigital Connection of Patients with Caregivers

  12. Crossing the Quality Chasm Care is Based on Continuous Healing Relationships New Model of Medical Practice Patient Centered Medical Home The First Rule of Redesign

  13. 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

  14. Young Can’t Imagine Life Without Online Access Associated Press December 5, 2004

  15. Why Use E-Visits? • Improve patient access • Enhance patient education • Increase patient satisfaction • Reduce telephone time and costs • Can balance risks and benefits • Competitive advantage • Transform work schedule

  16. Benefits of E-Mail • Visit extender - increased communication • Patients forget questions • Intimidated face-to-face • Enhance participatory relationship • Change service utilization • Behavioral coaching

  17. Potential Problems with E-Mail • Confidentiality and security • Time demands • Misinterpretation • Inappropriate uses • Digital divide

  18. Myths About Patient E-Mail • Myth #1: Hackers could read my patient’s confidential messages. • Myth #2: It will take more time from my day, and I won’t get reimbursed for it. • Myth #3: If I allow patients to e-mail me, I will receive a flood of e-mail messages. • Myth #4: Patients will ramble. • Myth #5: I may get sued, and a lawyer will discover my e-mail messages.

  19. 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

  20. LDL Management May Be Easier With E-Mail • Family Practice News, July 1, 2004 • William T. Lester • Randomized Trial at Mass Gen Hosp • Better Management • Fewer Visits

  21. The Doctor Is OnlineSimply providing a surgeon’s e-mail address nearly triples the likelihood that a patient will contact the doctor about the surgery New York Times, Feb. 18, 2008

  22. 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

  23. Time spent on patient email is predictable… 1000 pts @ 5 min/email ≈ 8 hrs/week/1000 pts 1000 pts @ 10 min/email ≈ 16 hrs/week/1000 pts

  24. 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

  25. New Schedule • Begin e-mail 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 in 2 sessions lasting 30-45 min. each • Done at 5:30 PM • Patients served -- 50

  26. A New Model of Office Practice • 50% More Caring Interactions Each Day • 10-12 Unhurried Office Visits Each Day • Advanced Access – Do Today’s Work Today • Patients Get All the Time They Need • Patients Receive the Excellent Care

  27. 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

  28. 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

  29. 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

  30. Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services

  31. 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

  32. Financial Models for the New Model • Shift of telephone to E-mail (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

  33. Finances Follow Innovation The New Model is More Efficient Better Faster Cheaper!

  34. The Secret Sauce for Success • Care becomes continuous access rather than episodic • Care becomes proactive rather than reactive • Patients become activated for self-management

  35. Relationship Centered Care What is the 21st Century Application?

  36. 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. Wise Words from Dee Hock

  37. Change Is Disturbing When It Is Done To Us. Change Is Exhilarating When It Is Done By Us Rosabeth Kantor Harvard Business School

  38. Human Nature Changes LittleCaring Remains PrimaryWhat Changes Are The Tools And Methods We Use

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