It’s the Systems!
L. Gregory Pawlson MD, MPH
Executive Vice President NCQA
Core Presentation
Why Focus on Systems?
• IOM reports: “To Err is Human” and “Crossing the
Quality Chasm”
– both reports provided substantial evidence on critical
importance of systems (including evidence from
other areas (aviation)
• Evidence from a few RCT’s (measurement
benchmarking and feedback) and studies with
reasonable experimental design that systems
appear to positively influence quality and
efficiency
• Research showing variance on process
outcome measures explained more by
site/group than individual clinician
• Studies of Shortell, Wagner, Roblin and others on
importance of structure and organization
Physician Practice Connection and Patient Centered Medical Home
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Focus on systems allows change from
“blaming” individual clinicians for
mistakes and shortfalls to actions
related to improving systems to
facilitate clinician success
Physician Practice Connection and Patient Centered Medical Home
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Wagner Model for Effective Prevention
and Chronic Illness Care
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Moving from models to practice
• Provide additional evidence of linkages between
use of systems using structural measures, and both
quality and efficiency process-outcome measures
• Development of reliable and valid tools for
evaluating systems presence to use for both
research and implementing practice change
• Create structural measures that are directly
actionable and are free from major bias and
confounds at physician office practice
“microsystems” level
– Sample size
– Attribution
– Need for risk adjustment
• Link adoption and use of systems to payment
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Overlap in Content of PPC-PCMH-CCM
Delivery
System
Design
Clinical
Information
Systems
Decision
Support
P
P Patient Centered Medical Home
C
SelfManagement
Support
Community
Support
Wagner Chronic CareModel
What’s
Included?
(Infrastructure)
How Much
Used?
(Extent)
What
Evidence
Functions?
and Scoring
(Implementation) (Verification)
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Implementing and Evaluating PCMH
Inputs
Individual
Clinician-Staff
Attitudes, behaviors
and proficiencies
Programs
Tools
Office Systems
Decision Support
Information Technology
Delivery System Design
Patient Support
Patient Centered
Ongoing Care
Output
Evaluation
Educational
Support
MOC
(Boards)
Practice Evaluation Programs
Patient
Clinical Process &
Office
Experience
Outcome Measures
Systems
of Care
(inc overuse, resource use)
Assessment
Measures
(Recognition programs
(PPC)
Physician Practice
Connection
and Patient
(CG-CAHPS)
and/or
group/plan
data)Centered Medical Home
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Linkage of PCMH to Reimbursement for
“ongoing” care
Pay for Performance- Clinical and Patient Experience
Fee Schedule for Visits/Procedures
Payment per patient per month (or per year)
for level of “Patient Centered Medical Homeness”
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