Editor’s Note: The federal government’s Beacon Program provides funding to 17 communities that have already made inroads in the development of secure, private, and accurate systems of electronic health record (EHR) adoption and health information exchange. This is the second in a series of Health Affairs Blog posts in which leaders of several Beacon communities discuss their experiences over the first year of the program. The first post in the series was by leaders of the Central Indiana Beacon Community, and you can read later posts by leaders of the SE Minnesota and Inland NW Beacon Communities. The Beacon program’s first year was also the topic of a May 17 Washington D.C. event sponsored by the Office of the National Coordinator for Health Information Technology (ONC) and the Engelberg Center for Health Care Reform at the Brookings Institution, and a Twitter chat on Wednesday May 18 hosted by ONC’s Aaron McKethan.
As we enter the second decade of the 21st century, our healthcare system has been challenged to meet the Triple Aim of improving health care for individuals, improving health for populations and reducing healthcare costs. Electronic health information technology is a potential solution to many of the problems that currently exist. Electronic health records are available, more physicians are adopting them and now the federal government is incentivizing them to be used in a meaningful way. (Meaningful Use).
The question remains – how will physicians use electronic health data when they get it? Improving health outcomes through the use of data is a transformational activity that demands an additional set of skills for physicians – not to replace or diminish traditional clinical skills but to enhance those skills as necessary to propel health care delivery into the modern age.
The Beacon Communities have been challenged to combine health and IT goals to demonstrate improved health care results. The Colorado Beacon Consortium is currently working with primary care practices in seven counties of western Colorado. The IT goals of this project are to support the movement toward meaningful use of health information technology with practices that utilize electronic health records, and, across the community, through the involvement of an independent regional Health Information Exchange (Quality Health Network).
Combining Health IT With Additional Skills And New Approaches
The mere availability of data will not improve health care delivery and health outcomes. At the core of the Colorado Beacon Consortium approach is the belief that achieving the triple aim requires ready access to meaningful electronic health information in a provider community where physicians have learned additional skill sets and where new approaches have been fostered. These skills include:
- Chronic Care Management – approaching all care delivery interactions in a prepared and proactive way, as opposed to only managing acute episodes
- Team Based Care – using all team members (within and outside the walls of a practice) to their maximum skill level, instead of the physician assuming primary responsibility for all activities
- Quality Improvement – making process changes based on a series of small tests of change using Plan, Do, Study, Act (PDSA) cycles which allow a practice team to identify those changes that will, in fact, get the results they want.
- Measurement – using health information data to improve care delivery and outcomes
Additional skills are not embedded easily because they are typically relatively new. They require instruction, experimentation, and continuous monitoring with re-tooling to have the desired effect. They also require a change in the norms found in the current health care model to principles such as patient centeredness and shared decision making. Perhaps most importantly, the development of new skills within the primary care workforce entails approaching the work of health care delivery with a sense of curiosity (“I wonder if….? What would happen if we….?).
Rocky Mountain Health Plans (RMHP), one of the four not-for-profit organizations that sponsor the Colorado Beacon Consortium, has been on this journey since its founding in 1974. The organization, headquartered in Grand Junction, Colorado was created by physicians to improve access and care to all patients within a community and, out of necessity, built a strong foundation around the need to “do the right thing”. That looked then, and continues to look now, remarkably like the “new” concepts of a functional medical neighborhood with primary care physician-sponsored medical homes.
RMHP has members and providers across the state of Colorado. Many of these communities are rural in nature, and in some instances quite remote. The typical primary care practice is independent and averages about 3 providers. While it is a dominant payer, particularly in the Western half of the state (providing commercial, Medicare, Medicaid and CHIP health plans), RMHP is not the only payer. However, RMHP has a history of strong relationships based on the belief that providers want to do the right thing (though the system they work in frequently doesn’t make that the easiest thing to do) and the relationship between the provider and the patient should be promoted and facilitated, not infringed upon.
The health plan, in close collaboration with the Mesa County Physicians Independent Practice Association, was well positioned in the year 2000 to tackle an opportunity from the Institute of Health Care Improvement to participate in a Breakthrough Series Collaborative to improve the care of people with chronic illness. That experience and the work and learning of the following ten years changed the way the organization approached chronic illness care and led to a strategy that has now put RMHP and its partners in the position to further facilitate improvement and progress through the Beacon Community Program and participation in a Medicaid Accountable Care pilot.
Perhaps the most significant learning from the past ten years experience is the fact that breakthrough, sustainable change is a function of teaching and deploying additional skills. Our experience suggests additional new skills are required at every level of health care delivery, from the physician and all other providers, to the practice, to the community, to the patient.
The Colorado Beacon strategy for teaching and deploying additional skills and making the necessary paradigm shifts harkens back to the IHI Breakthrough Series, the Expanded Care Model and the Model for Improvement. Experience over time working with providers to embed the components of these models in their day-to-day practice has taught us there is not a “rifle shot” approach that works. The approach must be multi-faceted, appeal to all levels of staff involved in a practice and recognize differing styles of learning. It must be relevant, applicable, and reasonable for a busy practice, no matter the size, patient population or payer demographics. The approach must satisfy the will of a provider to make changes by allowing small scale testing of change and meaningful measurement. The approach must promote the spread and sustainability of change.
How is the Colorado Beacon Consortium accomplishing this? A structured interactive training curriculum is executed by Quality Improvement Advisors (QIAs) assigned to each of the 28 practices currently involved in the practice transformation initiative. Colorado Beacon has set a goal to reach 75 primary care practices by the end of the 2012 demonstration period. QIAs work with practice teams to evaluate and redesign workflows to become more efficient and effective in delivering care. This includes maximizing the collection and use of data for the purpose of continuous quality improvement. This work is accomplished across the table from the practice team, facilitating a team approach to problem solving and delivery of care. It also includes teaching through webinars rich with content, tools, and support and through the use of teleconferences for ongoing support.
The curriculum also contains quarterly one day Learning Collaboratives, which promote learning from other practice teams across the seven county Beacon region and from nationally recognized experts in the areas of leadership, change management, and clinical focus areas, the Expanded Care Model, the Model for Improvement, and Measurement for Improvement. The additional skill sets introduced during the Learning Collaborative are implemented during the subsequent action periods. This work is accomplished through ongoing quality improvement coaching, ongoing repetitive problem solving, techniques such as process mapping, and monthly reporting.
What does the future hold as a result of the Colorado Beacon Consortium’s work? Through the ongoing development of a regional data base used to provide care in a more coordinated, patient centered way, the health of populations could be improved. Improved health has the potential to reduce costs. The data base may further be utilized to support an individual and population risk assessment tool, Archimedes, designed to assist physicians and patients in prioritizing health interventions in a meaningful way. The emerging tools and technologies that are now available to communities such as one served by the Colorado Beacon Consortium are compelling, but they will only be effective in the hands of patient-centered teams with sufficient skills to put them to use.