CMOs and
Implementation
Science Researchers:
A productive
partnership for
clinical improvement
Sponsored by CMOG and ROCC
Andreas Theodorou, M.D.
Russell Howerton, M.D.
Laura Peterson, M.D.
Hosted by Alexander Ommaya, D.Sc. and
David Longnecker, M.D.
Guest Speakers
• Russell Howerton, M.D.,F.A.C.S., CMO of
Wake Forest University Medical Center
• Andreas Theodorou, M.D., CMO of the
University of Arizona Medical Center
• Laura A. Petersen, M.D., M.P.H., F.A.C.P.,
Associate Chief of Staff for Research, Houston
VA Medical Center, Director VA HSR&D Center
of Excellence, and Professor of Department of
Medicine, Baylor College of Medicine
Q& A Communication
During the presentation, your telephone
line will be muted
To submit questions for the speakers,
please use the chat box on the lower right
side of your screen
Agenda
12:30 Introduction
David Longnecker, MD
Alexander Ommaya, D.Sc.
12:35 Russell Howerton, MD
12:45 Questions
12:50 Andy Theodorou, MD
1:00 Questions
1:05 Laura Petersen, MD, MPH
1:15 Questions
1:20 Next Steps
1:30 Adjourn
AAMC Implementation
Science/CMO Webinar
Monday March 25th, 2013
Observation Unit Stress Imaging to
Manage Patients with Intermediate
to High Risk Acute Chest Pain
Objective
To reorganize existing resources to deliver care in
a way that reduces hospital readmissions among
patients with intermediate to high-risk chest pain.
Wake Forest Baptist Health
Vashi et al. JAMA 2013
Study of 5 million hospital
admissions
Chest pain
discharges at 30
days:
PCI-related
discharges at 30
days:
12% had treat
and release
ED visit
7% had treat
and release
ED visit
10% had
hospital
readmission
13% had
hospital
readmission
Wake Forest Baptist Health
A possible solution: Observation Unit –
Stress Imaging Care Pathway
• Highly efficient units driven by care algorithms, staffed by
midlevel providers
− Efficient and cost effective in low risk patients
ACC/AHA:
Class I recommendation endorses OU care
Institute of Medicine:
“…clinical decision units reduce boarding
and diversion, avoid expensive
hospitalization, and appear to contribute to
improved management ...”
ACC / AHA NSTE ACS guidelines: Anderson et
al. Circulation 2007;
Wake Forest Baptist Health
Higher risk = high complexity
High risk
Higher complexity = higher
readmission rate
• 25-40% with pre-existing CAD (1-3)
•Perceived complexity inhibits
development of care algorithms
Is OU care an alternative to
inpatient care?
•Cost?
•Event rates after discharge?
•Readmission rates?
Intermediate
risk
Lower complexity:
•Care easily integrated into
care algorithm
Low risk
1.
Very low risk
Tatum et al. Ann Emerg Med, 1997
Stowers et al. Ann Emerg Med 2000
3. Gomberg-Maitland et al. AHJ 2005
2.
Proven efficacy of OU care:
• Low event rates
• High patient satisfaction
• Widely adopted
Methods
• Design for 2 RCTs conducted at Wake Forest
Patients at
intermediate to
high-probability
for ACS
Inpatient care
ED
eval
Care per
individual
providers
Randomize
Observation
unit
Serial
biomarkers
Stress imaging
Wake Forest Baptist Health
Follow up
through 1
year
Cost of OU care versus Inpatient care
(Miller et al. Ann Emerg Med 2010)
(Miller et al. JACC:Imaging 2011)
Analyses based on intent to treat
Wake Forest Baptist Health
Trial 2 Primary outcome: Composite
Readmit, Revasc, Recurrent testing
Inpatient
38% vs 13%,
P=0.004
OU Care
OU Care Inpatient
P
7 (13%)
20 (38%)
.004
Revascularization
1 ( 2%)
8 (15%)
.031
Hospital readmission
4 ( 8%)
12 (23%)
.033
Recurrent cardiac testing
2 ( 4%)
9 (17%)
.028
Composite
Wake Forest Baptist Health
Combined events, Trials 1 and 2
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
82%
OU
Inpatient
28.2%
8%
Index visit admissions
13.5%
2.9% 10.9%
Cardiac hospital
Revascularizations
readmissions
Observation Unit Inpatient
Adverse Events
Death
1/104 (1.0%)
0/110 (0%)
MI (after randomization)
6/104 (5.8%)
5/110 (4.6%)
Wake Forest Baptist Health
Summary
• OU care with perfusion imaging at Wake
Forest:
− reduces cost, readmissions, and revascularization
procedures
• Death and MI
− Very low rates with either strategy
• Leverages and reorganizes existing resources
to achieve these benefits
Wake Forest Baptist Health
Future directions and opportunities
• Implementation:
− Can benefits observed in single center trials be
achieved in a multi-center setting?
• Implementation study with outcome surveillance
− Are results dependent on using cardiac MRI as the
imaging modality?
• How can we remove barriers so we can
organize EMRs to automate data capture and
outcome surveillance across medical centers?
Wake Forest Baptist Health
Musculoskeletal Emergency Center
• Development of an integrated practice
unit (IPU).
• Replace physician-centric processes with
patient-centric ones
• Decrease the distance between patient
and final decision-maker.
• Prospective database to monitor clinical
outcomes.
• “Maximize Value. Optimize Education.”
Wake Forest Baptist Health
Areas for Multicenter Collaboration
• Develop evidence-based clinical
practice guidelines
• Develop competencies and
standardized education for the new
field of Musculoskeletal Emergency
Medicine
• Enhance understanding of
operational efficiency and timedriven activity based costing
• Multicenter prospective database
• Create best practices in this field
Wake Forest Baptist Health
Questions?
3
Healthy Together Care Partnership
Healthcare Dream– Implementation
Nightmare
Amd
Andreas A. Theodorou, MD, FAAP, FCCM
Chief Medical Officer
University of Arizona Medical Center
Professor and Associate Chair, Pediatrics
20
UAHN – Quick Overview:
Includes two hospital campuses -The University of Arizona Medical Center
(University Campus, including Diamond Children’s) & (South Campus)
40 clinics, a health plan division and practice plan for physicians from the
University of Arizona College of Medicine
Only Level 1 Trauma Center in Southern Arizona – (University Campus)
Comprehensive Transplant Program(University Campus)
NCI Designation
University & South Campus Patient Statistics 2012-13:
University Campus &
South Campus
Admissions
20,489
Emergency Visits
74,632
Total Net Revenue
533193
Patient beds
592
21
COMMON CMO PRIORITY ISSUES
•
•
•
•
•
•
•
•
•
•
•
Hospital/Healthcare-associated Infections
Core Measures
Procedural Complications
Dual-Eligible
Falls
Patient Satisfaction
Access to Care
Patient Through-Put
Safe Medication Use
Readmission Rates
Hospitalization Avoidance
Continuity of Care
The Healthy Together Care Model
• Focuses on approximately 345 dual eligible Special
Needs Plan members within our University of Arizona
Health Network
• Designed to improve quality of care for this high risk/high
cost population living in the home and community
23
HEALTHY TOGETHER POPULATION
UAHN Health Plans
Dual Eligibles in Pima
County (n≈4,000)
UAHN Health Plan
Duals in Pima County
assigned to UAHN
primary care provider
(n=345)
All UAHN Health
Plan Duals
(n≈9,000)
• Early data indicate
that sub-population
health risk and cost
profile is representative
of all UAHN Health
Plans dual-eligible SNP
population and the
national dual-eligible
population
COST OF CARE
5%
15%
48%
30%
n=345
37%
50%
14%
1%
Within our sub-population, the costliest 5% of enrollees account for 48% of
total cost of care, while the costliest 20% account for 85% of total cost*
•Based on retrospective chart review and analysis of 307 dual eligibles with UAHN Health Plan coverage and
assigned to primary care with a UA Health Network provider (Goel, et al, 2011)
THE CARE MODEL USES MULTIPLE EVIDENCE
SUPPORTED STRATEGIES
• Interprofessional team-based care
• “Home-based Primary Care” for ~ 45 most complex and
homebound (with telehealth)
• Case management and telehealth for rest of cohort, in
collaboration with primary care providers
• Medication Reconciliation
• Integrated behavioral health/physical health care
management
• Patient Engagement and Shared Decision Making
26
HEALTHY TOGETHER CARE PARTNERSHIP
– Delivery System/Health Plan Partnership designed to
reduce utilization in a high risk/high utilizing population
– Targeted utilization reduction in population
• Decreased ED Utilization
• Decreased Cost of Admissions
• Decreased Readmission Rate
• Decreased Med Cost by Pharmacy Review
– Net savings if targets achieved: $1.5 Million
Good News
• Primary goals of the program include cost savings, improved quality
and satisfaction with care, blended physical and behavioral health,
development of individualized strategies to manage at-risk
patients, and development of best practices for dual eligible patients
in SNP community care settings.
Bad News
• 18 months later the project had still not started!
– Overcoming Academic Medical Center Inertia: Building an Innovative
Dual Eligible Service Line
Great News!
• Project now fully launched and first 4 patients enrolled last week!
28
REASONS FOR DELAYED IMPLEMENTATION
•
•
•
•
•
•
•
•
Organizational Complexity
Clinical Cost Structures
Training Expectations
Credentialing and Privileging of NPs
Employment/supervision of NPs, SWs and RNs
Who Provides Space and Infrastructure
Non-integrated Information System
Coding and Compliance Issues
LONG TERM PLANS
• Eventual development of a stand-alone product that would provide
coverage to the entire population of dual-eligible SNP patients resulting
in reduced costs and better outcomes (e.g., lower hospitalization rates,
better medication compliance, improved morbidity and mortality)
-Year 1: Dual-eligible patients in UAHN care (n=345), starting with
highest-cost stratum, and rolling additional services out to remaining
patients in lower-cost stratum.
-Year 2: Expand to include SNP patients in Pima County
-Year 3: Expand to include remainder of SNP
• Savings realized through better care of high-cost stratum would be the
basis of funding novel programs for the entire SNP population
Current state
Healthy
Together Pilot
Stand-alone product
for all UAHN SNP
patients
30
HEALTHY TOGETHER DEVELOPMENT TEAM
•
•
•
•
•
•
•
Jane Mohler, NP-C, MPH, PhD1,2;
Nancy Wexler, MPH1;
Richard Slaughter3;
James Stover3;
Patricia Harrison-Monroe, PhD1;
Tom Ball, MD1,2;
Mindy Fain, MD1,2
•
UA, College of Medicine1; Arizona Center on Aging2; UA Health Network, Health Plans3
31
31
Questions?
CMOs and Implementation Science
Researchers: A Productive
Partnership for Clinical Improvement
Laura A. Petersen, MD, MPH, FACP
Professor of Medicine and Chief, Section of Health
Services Research, Baylor College of Medicine
Director, Houston VA HSR&D Center of Excellence,
Associate Chief of Staff for Research, Michael E.
DeBakey VA Medical Center
March 25, 2013
Petersen AAMC Webinar
Iraq, March 2003 – Embedded journalist Chip Reid, right, travels through southern Iraq with
soldiers from the 3rd Battalion, 5th Marine Regiment.
Petersen AAMC Webinar
Partnerships Between Researchers and
the VA Health Care System
• Partners include national program offices, regional
CMOs and facility leadership, clinical leaders and
managers, and individual clinicians
• Increase impact of research on Veteran health by:
– Ensuring appropriate input into research priorities from a
variety of VA stakeholders
– Encouraging ongoing communication between research
and operations
– Enabling more timely response from the research
community to emerging health system issues
– Facilitating effective communication of research results
and uptake of research into practice (implementation)
Petersen AAMC Webinar
Translation/Implementation Highways
From: Practice-Based Research—“Blue Highways” on the NIH Roadmap
JAMA. 2007;297(4):403-406. doi:10.1001/jama.297.4.403
Hold for cartoon
Petersen AAMC Webinar
Problems with Linear Translation
• T1  T2
– 17 years from basic discovery to clear evidence from
clinical trials
Contopoulos-Ioannidis et al. Science 321:1298-99
• T2  T3
– 10 years for widespread guideline implementation
• Linear approach to translation creates excessive lag
in evidence implementation
Pr
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er
Re eyo s or
(ex sea rs o
HS : Ho rch f
R & us
D C ton
oE
)
Pr
o
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rv
er
Re eyo s or
se rs
arc of
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Pr
od
uc
ers
(ex
o
o
:H
ou f Res r Pu
sto
r
n H earc veyo
rs
SR h
&D
Co
E)
Petersen AAMC Webinar
Model B- User pull efforts
rs
se
h U 12)
arc
se ISN & 3
Re ex: V ts 1
(
jec
Pro
f
po s
rou ser
e G h U 2)
On earc N 1
IS
s
R e ex: V
(
Model C- Exchange efforts
f
po
rou h
e G arc
On se s
Re ser
U
f
po
rou h
e G arc
On se s
Re ser
U
Model A- Push efforts by
producers or purveyors
Pr
o
Pu duc
rv
er
Re eyo s or
se rs
arc of
h
Models for Linking Research to Action
Knowledge
Translation Platforms
(ex: AFHIL & VINCI)
Projects 2 & 4
Model C- Exchange efforts
Adapted from Lavis et al, 2006
Technical Problems vs. Adaptive Challenges
(from Ronald Heifetz and Marty Linsky, “Leadership on the Line”)
“The single biggest failure of leadership is to treat adaptive challenges like technical problems”
Technical Problems
1.
2.
3.
4.
5.
6.
Easy to identify
Often lend themselves to quick
and easy (cut-and-dried)
solutions
Often can be solved by an
authority or expert
Require change in just one or a
few places; often contained
within organizational
boundaries
People are generally receptive
to technical solutions
Solutions can often be
implemented quickly-even by
edict
Petersen AAMC Webinar
Adaptive Challenges
1.
2.
3.
4.
5.
6.
Difficult to identify (easy to
deny)
Require changes in values,
beliefs, roles, relationships, &
approaches to work
People with the problem do the
work of solving it
Require change in numerous
places; usually cross
organizational boundaries
People often resist even
acknowledging adaptive
challenges
“Solutions” require experiments
and new discoveries; they can
take a long time to implement
and cannot be implemented by
edict
Examples from Health Care
Technical Problems
1.
2.
3.
4.
Implement electronic ordering
and dispensing of medications
in hospitals to reduce errors and
drug interactions
Improve availability of hand
sanitizer
Create workflow and structure
to deal with low risk chest pain
patients in the ED
What are the appropriate peer
facilities for quality and
efficiency comparisons
(Partnership project)
Petersen AAMC Webinar
Adaptive Challenges
1.
2.
3.
4.
Encourage nurses and
pharmacists to question and
even challenge illegible or
incorrect prescriptions by
physicians
Get health care providers to
improve hand washing rates
Change primary care team roles
to adopt a patient centered
medical home model
(Partnership project)
Design and test new model of
provider payment to reward
quality (Partnership project)
Researchers Can Help with Evidence to Overcome
Both Technical and Adaptive Challenges
• What are the social, cognitive, workflow
barriers to handwashing?
Petersen AAMC Webinar
Examples of Partnership Projects at the Houston
Health Services Research and Development
Center of Excellence
• Longitudinal measures of quality (Petersen and
Woodard, PIs) – 10 publications (Circulation,
Medical Care, JAGS, HSR, Diabetes Care)
• Resource efficiency (Petersen, PI) – 7 publications
(HSR, Medical Care)
• Hospital and community living center peer
facilities (Petersen, PI) – 2 publications (HSR,
American Journal of Managed Care)
• Evaluation of primary care re-design (Hysong, PI)
• RCT of pay for performance (Petersen, PI) – 3
publications
Petersen AAMC Webinar
Understanding Differences
• Network Needs:
– Value fast turnaround, practical projects rather than publications
(implementation/external validity)
– HSR&D cheaper, more knowledgeable than external consultants
– “It doesn’t really have to be perfect”
– Rapidly changing needs, priorities
• Research Needs:
– Academic products
– Internal validity focus
– Slower pace (IRB, funding cycles, data use agreements, HR,
credentialing, contracting)
– Business model
Credentialing
Contracting
VA Research
HR
Petersen AAMC Webinar
Challenges to Partnerships
• Regulations!
– Data Use Agreements
– Research training for non-researchers
• Business model
Petersen AAMC Webinar
Advantages of Partnership
For Researchers
•
•
•
Aligning research with
specific health system
partners to increase the
impact on VHA
Accelerating the
timetable for research
in areas critical to the
health system
Focus upon
implementation early in
the research process
Petersen AAMC Webinar
For Partners
•
•
•
Embedded researchers
are cheaper and more
knowledgeable about
the delivery system
May have access to
data that other
consultants don’t have
Diverse skill set to
tackle problems
Building and Maintaining Partnership
• Need champions within partnering organization
• Some face to face meetings, especially early on
• Continued mutual recognition of needs of
partnering organization
• Continued attention to sustainability
• Appreciation of differences
Petersen AAMC Webinar
Partnership Research is a Team Sport
• Doing partnership work requires an excellent
team
• Ability to respond to questions and requests
• Relationships, relationships, relationships!
Petersen AAMC Webinar
Petersen AAMC Webinar
Questions &
Next Steps