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Disruptive Innovations to Achieve Right Specialty Care February 24, 2017. Hal F. Yee Jr., M.D., Ph.D. Chief Medical Officer Los Angeles County Department of Health Services. Disclosure. I do not have relevant financial relationships with commercial interests. GME/CE Learning Objectives.
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Disruptive Innovations to Achieve Right Specialty CareFebruary 24, 2017 Hal F. Yee Jr., M.D., Ph.D. Chief Medical Officer Los Angeles County Department of Health Services
Disclosure I do not have relevant financial relationships with commercial interests.
GME/CE Learning Objectives • Recognize the critical importance of disruptive innovations in health care delivery. • Demonstrate how health information technology can genuinely improve the effectiveness and efficiency of health care delivery. • Recommend how the health care safety net represents a unique model for creating and testing disruptive innovations.
LA County DHS (ca. 2011):Some Challenges • Scale • 88 cities, 10M residents, 2M uninsured • Infrastructure • Absence of unique patient/provider IDs, EHR, real primary care, standards, or coordination • Governance • Bureaucracy, politics, civil service, silos • Disparity between demand & capacity
Los Angeles County: Scale Chicago Houston New York City San Francisco Philadelphia District of Columbia Data Source: U.S. Census Bureau, Topologically Integrated Geographic Encoding and Referencing system, 2009. Maps Drawn at 1:750,000 scale. 5
The Problems Patient-Centered Medical Neighborhood PCMH Specialty Home PCP Specialist Clear Consistent Coordinated Timely Efficient Cost effective Ambiguous Inconsistent Discoordinated Untimely Inefficient Costly Disruptive Innovations: • Specialty-primary care work groups • Expected clinical practices • Electronic consultations
The Solutions • Disruptive innovations: implement novel processes that greatly increase access through simplicity and cost reduction • Address key barriers to change: • technical (i.e., policies and procedures) • adaptive (i.e., culture and behavioral)
Specialty-Primary Care Workgroups • What is the disruption? • How does it address the technical and adaptive barriers? • Improves consistency, coordination, efficiency, and cost effectiveness.
Expected Clinical Practices • What is the disruption? • How does it address the technical and adaptive barriers? • Improves clarity, consistency, efficiency, and cost effectiveness.
Specialty-Primary CareExpected Practices • Developed by Specialty-Primary Care Work Groups composed of specialists and primary care providers • Guided by 1) real-life practice conditions, 2) available clinical evidence, and 3) the principle that we must provide equitable care for entire patient population • In individual situations a provider’s clinical judgment may vary from an Expected Practice, but in such cases compelling documentation for the exception should be provided.
Expected Practices: Examples • Cancer screening (e.g., breast, colon) • Evaluation and management of specific conditions • Specialty care co-management recommendations • Standard logistical information (e.g., ‘how to do X’)
Electronic Consultations • What is the disruption? • How does it address the technical and adaptive barriers? • Improves clarity, consistency, coordination, timeliness, efficiency, and cost effectiveness.
Impact • Ability to track, triage, advise, avoid • Wait times/Access to care • Dialog and relationship building • Elimination of illegible faxes • Improved specialist efficiencies • User experience and education
Bibliography • Chen, A Hm, Murphy, EJ, Yee HF Jr, eReferral - A new model for integrated care, New Engl J Med, 368:2450-3, 2013. • Yee, Jr HF, The Patient-Centered Medical Home Neighbor: A Sub Specialty Physician’s View, Ann Int Med, 154:63-4, 2011. • Soni, SM, Giboney, P, Yee, HF Jr, Development and implementation of expected practices to reduce inappropriate variations in clinical practice, JAMA, 315:2163-64, 2016. • Barnett, ML, Yee, Jr HF, Mehrotra, A, Giboney, P, Widespread adoption of electronic consultations in a large safety-net system enables rapid access to specialty care, Health Affairs, in press, 2017.