The Group Health Medical Home
Can it be implemented in Aotearoa?
Jim and Ruth Vause
May 2011
GPonline Ltd
Blenheim
Group Health, (Seattle USA) has implemented a model of general practice care called the Group
Health Medical Home (GHMH) that offers a number of key features that may help NZ general
practices meet the looming problems of workforce and resource limitations set against an
environment of aging population and increasing service demands.
This report is an outline of the findings of a visit to Seattle during February 2011 in which the
authors identified key features of the Medical Home that could be implemented in a typical NZ
general practice without requiring the significant total health system redesign that would be
required to replicate the model in totality.’ This report focuses on practice level implementation and
in no way attempts to address the issue of integration with secondary services and thus is not
encumbered with possible difficulties associated with such integration. It is presumptive of the
primary care environment outside of the practice being that which can be assured to be universally
available in NZ, in other words the lowest common denominator of PHO or IPA services. In regions
with substantially better practice support, be it as currently exists in more advanced PHO/IPA
environments or the proposed Integrated Family Health Centres, implementation of the Group
Health model should obviously be significantly easier assuming that practice support is not restricted
to physical premises and that it allows clinical lead system design with appropriate IT support.
Essential preliminary reading is the Midland Health Network Seattle Findings Report of October 2010
which can be found online at
https://provider.midlandshn.health.nz/clinical/uploads/Main/BSMC-MHN-SeattleFindings.pdf
The Midlands report more than adequately outlines the key components of the Group Health
Medical Home (GHMC). Part one of this report summarises the same but adds further information
on the role of guidelines, evidence and clinical pathways in the GHMH. Part two is an evaluation of
translating the model to a typical New Zealand general practice, based on the authors’ experience
not only of the development of their own 5 doctor practice, but also on knowledge gained visiting
some 110 practices across the nation as both RNZCGP Cornerstone Assessors and practice
consultants.
Therefore this report will be useful for practices planning to address the issues of practice
sustainability for the next decade.
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Part one:
Background: the burning platform
Extrapolation of historical data trends suggests that the workforce in NZ general practice will
become increasingly strained over the next decade by the aging baby boomers who will not only
increase the demand for health services, but will also move out of the practice workforce into
retirement. This, in conjunction with the increasing complexity of primary care, (especially chronic
care) along with a reduction in secondary services will mean that if NZ to continue to provide
appropriate primary care, either we need an increased number of new entrants into NZ general
practice (be it NZ trained or overseas) or the provision of primary care services needs to be
redesigned.
Given the complexity and difficulty that workforce planning in NZ has encountered to date and the
fact that primary health care systems in OECD countries face the same problems as we do, the latter
course of action needs to be planned and actioned.
To this end we, the authors, visited Group Health in Seattle USA to explore further the possibility of
implementing some of the concepts of the Group Health Medical Home.
Why Group Health
Group Health is a large mainly primary care consumer governed organisation in Seattle, Washington
USA providing care to 654,000 enrolled persons. (larger than any NZ DHB) GH has a long history of
association with NZ, in particular with NZGG and evidence based medicine. They have faced and are
dealing with similar burning platform issues to those that NZ faces, their answer being the GH
concept of the “Medical Home”
Issues leading to their changes were

Unsustainable workforce (Doctors and nurses)

A growing percentage of part time practitioners

Recruitment and retention problems and costs Workforce dissatisfaction was high as they
had “squeezed” primary care physicians to increase productivity

Need to improve quality which had been dropping.
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The Group Health Medical Home
Below is a brief outline of the structure and processes of the GHMH. For more in depth information
please read the Midland Health Network report
What is Group Health (GH)?
A consumer governed co-operative, participant persons (patients) are those who pay to join Group
Health either themselves or as part of their employment. One arm of GH is essentially a funding
organisation raising money by way of selling plans to individuals and employers. The other arm is a
provider organisation which was the area of our interest. This has

29 groups practices across the Washington State, largely in Seattle

1 hospital (largely day stay)
All these are owned, governed and managed by GH
GH has focused over the past few years on reducing their organisation’s dependency on and
investment in hospitals recognising that, in having an organisational focus on reducing hospital
admission and re-admission rates through providing high quality primary care, it was more efficient
to purchase services from existing hospitals rather than owning them.
In addition to its practices, GH has an affiliated network of approximately 9,000 community
clinicians and 41 hospitals. These networked practices and hospitals are independent of GH and
usually provide care on a fee for service basis. They relate to GH much like GPs, private hospitals
and private specialists in NZ relate to insurance companies such as Southern Cross. GH has to use
these networks largely for essential hospital services and for provision of care (primary and
secondary) for patients in geographic areas not well covered by GH. As a guide patients must have
clinicians within a 15 mile radius. This “network” is a significant problem for Group Health because
of the difficulties they have in influencing and engaging with the clinicians and management of those
practices.
Some key differences with NZ General Practice

The hard to reach, disengaged and those who cannot afford are not in Group Health
Group Health Governance:
Is by the community with additional community input in many stages of service planning. The
governance is consistent across all levels of care and avoids dis-coordinated governance typical of a
multi-tiered health system of different organisations.
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Group Health Management:
Lean thinking:
This is a key process of Group Health’s management and contrasts with MBA type management as
typical of much of USA commerce.
Practices:
Each GH clinic location can have up to 30 doctors plus ancillary staff. They are usually organised into
practices of 4 docs, one practice assistant/nurse practitioner, one registered nurse, two licenced
practical nurse and 4 medical assistants (refer to table: scan in table)
The clinic's registered nurses, licensed practical nurse, medical assistants, and receptionists are
linked in triads to form care teams. The nurse (RN or LPN) is responsible for telephone consultation,
direct patient care, and practice management. The medical assistant (MA) is responsible for
maintaining the clinic flow, maintaining the exam rooms, and proactively reviewing patient
registries.
The Medical Home
To deal with the workforce issues, aging population and increasing complexity of health care, GH’s
Medical Home aims to reduce face to face consultations by providing other options for patient
access to care, including enhancing self-care and extensive use of non-medical clinicians, integral
with the application of standardised processes in the following realms:
1. Reduced direct F2F interaction between patients and GPs by
a. Use of “virtual medicine”. Patients have access On-line to their tests, problems lists,
drug list, care plans and clinical advice (real time web consults and secure
messaging). Uptake of online access by patients is about 60%.
b. “First call’ management focused on dealing wherever possible with patient’s
problems at the time of their first contact with the clinic for that problem, rather
than getting back in touch with the patient later on.
c. Increased patient self-management
d. Technology transfer where appropriate away from highly skilled difficult and costly
to train clinicians to those more easily trained
2. Standardised care
a. To reduce needless medical and management variation, but allow patient
determined variation where consistent with evidence and contextual factors.
b. Designed at the practice/clinician level and appropriately trialled and refined before
implementation across the organisation.
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c. Evidence based medicine critical for key clinical decisions is central to this and
facilitated by the GH PMS system
d. Audit and performance measures relating to care are consistently applied across the
organisation.
3. Implementation of changes and quality assurance is achieved by standardised systems of
management across all practices. Processes of team work, distribution of information, audit
and feedback are standardised and consistent
Virtual medicine
The average GH Family Physician does 14 face to face consultations per day within a total of 35
consultations per day, the extra being phone consults, email (secure messaging) or virtual web
interactive consults
Examples

A diabetic patient is being transferred onto insulin. The decision is made by the Family
Physician in a phone consult with the patient. The doctor completes the script, the patient
education and resources (needles, pens, etc.) are provided via the nurse, the patient
accesses an interactive protocol on the GH website via a link in his/her patient record, with
telemonitoring and follow-up by the nurse or practice assistant.

INR management is performed centrally: All management of warfarin is done by a central
office for all of Group Health. The practices doctors have no involvement.
First Call
While the concept seems little different from many similar telephone triage systems, this differs in
have a focus on solving the patient’s problem when they ring or contact the clinic and failing this,
providing a clear next step for the patient at the contact time. This requires careful analysis of
workflow and designing the IT and communication system to support the reception and clinical staff.
Standardised care
Processes within the clinical units of GH focus strongly on standardised care, predicated on reducing
needless medical variation but not reducing patient focused variation where appropriate. The
standardised care is designed by clinicians, based on evidence and consensus, and is continually
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reviewed and modified according to need, as is the Information Technology (IT) and other associated
services. Consumers groups also contribute to clinical system design.
Key features of standardised care are
o
Clinician designed
o
Evidence based
o
Includes standardised resource availability and structure of cares
Caveat:
Obviously clinicians who have difficulty functioning in the standardised care environment do not stay
with GH. New applicant Family Physicians were, like younger GPs in NZ, more accepting of the GH
setup, facilitated by the induction process for new staff. The large pool of Family Physicians in a city
the size of Seattle did allow GH to use “natural selection” of their doctors. However I note that there
was no shortage of senior Family Physicians of a similar age to myself who were praising of the
system, especially its ability to reduce needless administrative work.
Information technology
EPIC is the clinical software used by GH, being a GH only product and thus is responsive to their
needs. The system was evaluated in NZ by the G8 project and provides patient management system
(PMS) management and quality facilities in addition to the patient portal. It functions much like NZ
primary care IT systems but is more sophisticated being designed for the organisations needs and
thus is closely integrated as opposed to our more distributed NZ systems. This close integration is
important for the delivery of quality care.
Caveat:
These observations are largely as reported by various clinicians (usually senior) that I talked to
during the visit. I had minimal opportunity to see the PMS system in action, only about ½ hour with a
nurse who was using EPIC for clinical care. The guideline team confirmed how EPIC was used for
assuring standardised care and these comments was triangulated against other sources of
information on EPIC.
The critical place of evidence in Group Health
Group Health has a unit dedicated to evidence implementation, in line with their long history of
evidence based medicine and guideline work. The difference between GH and NZ is that their ability
to implement evidence is largely a result of common clinical, management and quality systems
throughout the whole organisation. Thus evidence is tightly integrated into the organisation, not
just clinical but also management.
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The GH guideline unit has 60 odd guidelines on their database which are reviewed every 2 years for
currency. For new guidelines, they largely use existing guideline where possible from reputable
sources (NICE, SIGN).
Adaptation of outside guidelines to the GH environment is relatively easy as their service provision
follows evidence on effectiveness and efficiency and there is minimal need to adapt guidelines to the
type of resource limitation imposed in this country by multiple tiers of health management, and the
politics of government, MOH, DHBs and PHOs. As an example, if the evidence shows that it is more
effective for a GH Family Physician to order MRI for a given problems or possible diagnosis, then this
is carried out via appropriate decision support tools. Thus care follows evidence and not silo’d
funding stream limitations, with the resource allocation driven by evidence or effectiveness and
efficiency.
Caveat:
Interestingly there does not appear to be the same degree of patient involvement in guideline
development as in NZ. The concept of cultural context to evidence interpretation was also not
evident in their guideline work.
Evidence Implementation
GH uses typical processes (CME, CNE, website publishing, IT, audit) for implementation of new care
and evidence. The standardised structure and processes (management, clinical and quality) across
their organisation means that efficiency of implementation is high.
As an example of such processes, new information is disseminated by electronic means, is shared at
the start of day practice huddle. There is transparent presentation of regular performance quality
audit information in each practice (unit and individual) and the IT system allows new evidence to be
related “just in time” for clinical decision making.
Caveat:
By contrast, their ability to implement in their affiliated network is very low, reflecting not the
quality of the evidence but the different organisational structures outside GH.
Care Pathways
GH does not use clinical pathways in name. The organisational focus on standardised care
(standardised processes, both clinical and organisational) with a strong place for evidence in the care
is in reality cafe pathways, particularly as it extends to 2ry care within the organisation e.g.
outpatient or day stay procedures.
Caveat:
This does not apply to GH patients in care with their “network” providers, be it primary or
secondary care.
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Summary
The Group Health Medical Home effectively addresses many of the issues facing primary care
through a complete health care system focused on meeting the patient need within resource
constraints.
A unified structure, lean management thinking and clinical systems designed from the ground up
alongside close integration of management and clinical care are the key elements of the system, and
reflects not only intelligent design but also continuous quality improvement.
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Part two:
What can be implemented in the
average NZ general practice
To implement fully the GHMH model in NZ would require significant changes to health governance,
primary care ownership and health care management at all levels, from national down to practice.
The feasibility of such changes being implemented is remote for it would require not only a
significant capital injection into primary care, but also total redesign of contracting and health care
management processes. The current plans by the Midland Health Network may meet some of these
requirements but the structures of the NZ health system are likely to severely limit implementation. i
As a nation, New Zealand is very good at innovative health care pilots but fails when it comes to
widespread implementation of innovation, a feature that is part of our national psyche ii rather than
being unique to health. Students of history will be familiar with the failed innovations that litter the
annals of NZ primary health care. The GHMH mirrors the structure and process features of some
smaller NZ PHOs and IPAs, both mainstream and iwi but these have not been translated wider and
are now being lost in the amalgamation of PHOs . The key feature of NZ health care that is the major
impediment to implementation, namely complexity, appears to reflect our national psyche.
Lean thinking is central to GHMH processes but it will be difficult to implement with this country’s
multi-tiered hierarchy of health system governance, management and clinical structures and
processes. However there will be fewer barriers to this at the practice level for most have a flat
management structure and a strong clinical focus.
At the practice
The most significant prerequisite is a general practice that possesses the necessary structures and
processes that would allow lean thinking, standardised care and first call triage. Associated with this
is an IT capability that would allow implementation of the necessary communication pathways for
patients to access care through the digital media.
Such practices would need to have

Practice governance and management to be commensurate with the problems facing
general practice in the next 10 years, especially workforce and resource limitation and to be
capable of implementing change especially in work flow.
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
Management expertise for adaptation and implementation that is supported by practice
governance

Time and resources available to effect change

IT capability and support.
The implementation of the Medical Home would be greatly facilitated by a PHO/IPA network that
supports the practice to:

Devolve funding budgets to the practices in a shift away from fee for service.

IT support to facilitate patient access to their own medical information, with associated care
plans and educational and decision support systems.

appropriate IT to support development designed by the clinicians in the practices

IT Implementation of clinical pathways focused on standardised care
These four points are the focus of many national and regional development plans but it remains
uncertain as to their implementation in a consistent manner across the nation. However, as much of
the IT support required has already been implemented somewhere in NZ, we have presumed that
these would be available either now or in the near future to all practices.
Implementation Specifics
The design of the key areas below is outlined in the Midland Health Network Seattle Report. Please
refer to this for further information.
Standardised care:
Standardised care is essentially the primary care section of a clinical pathway. Presuming that a
practice already has appropriate clinical governance systems in place (some of this is covered in the
RNZCGP Aiming for Excellence Practice Standardsiii) implementation of standardised care should be
relatively easy given the capabilities of the main NZ PMS systems.
Evidence is central to standardised care, for it not only identifies key aspects of appropriate medical
care but also the factors that are necessary to consider when allowing for patient (not medical)
variation in care. This requires practices to be able to

Source and interpret evidence appropriately

Apply evidence to standardised clinical care.
The lack of a common source of reliable evidence information for NZ general practice is a major
barrier to evidence based standardised care process. While there are certain disease specific sources
such as the NZGG Cardiovascular Handbook, primary care clinicians cannot go to one NZ source for
all their evidence requirements. Some standardised care is documented regionally such as the
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Canterbury Pathways but are referral pathways as opposed to practice based care. There are also
examples of event specific standardised care such as Pharmac Special Authority criteria but these
are snapshot events, not continuous care.
Even where there is evidence based standard care, applying it in a practice can pose a challenge. This
can be addressed by getting clear agreement by clinicians on the appropriate standard of care and
then by instituting systems such as care templates and just in time reminders at key decision points.
Such decision points need to focus in particular on points in a care pathway where informed consent
is required from patients, Appropriate IT tools incorporated into the PMS (as per Group health) are
essential but are largely lacking in NZ.
Non face to face communication
Key to a higher use of non-face to face communication is orientation of the funding of clinicians and
practices with this objective. Capitation has altered some of this thinking but fee for service still
remains for ACC and many PHO funding streams. Alliance contracting offers an opportunity to make
progress in this direction; however the required thinking behind this and the associated capability
requirements on both sides of the alliance contracting table are likely to be beyond most PHOs and
certainly the great majority of practices.
First call triage: This will require significant alterations in the workflow and workforce in many
practices. Facets of such alterations will be

a move to use of complementary health practitioners (Practice assistants, Medical Assistants
etc.) While the scope and place of these roles is not currently clear, the opportunity is for
development of these at the practice level, orientated to the real clinical needs, as opposed
to academic determination of role. This would be consistent with a clinical “coal face” focus
as per the GHMH.

Closer integration of practice systems with Health Line and other afterhours telephone
services, especially with a centrally held medical record.

Improvement in the current PMS appointment system to allow patient organised
appointments and alternative patient practice communication (secure messaging)

Telephone system integration with practice IT
There are a number of IT solutions to meet the above last three bullet points which, while they
usually need further development, are a step in the right direction and will hopefully have their
development orientated in a consistent manner by the projects being run under the auspices of the
National IT Board.
Web based patient portal:
This will be essential for a more varied patient/clinician/practice interface. These will need to cover
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
patient central records

secure email

virtual eConsult

Careplans

links to resources for patient education and decision making
Quality: Unintended consequences:
Unco-ordinated practice level implementation could lead to significant care variation given our
propensity for “doing things my way”. Careful monitoring will be required, something that will prove
difficult given the existing difficulties with monitoring in primary care. Consider that a medical home
emphasis on digital access to primary health care would likely adversely impact upon patients
lacking digital access to the practice, thus strategies would need to be put in place to assure equity
of outcome through better access for disadvantaged persons. Existing primary care indicators for
monitoring access to care are poor and while there is some development under the National IT
Board, their relationship with quality improvement and quality assurance (including incentives)
remains tenuous and without leadership. Appropriately developed clinical governance in practices
and PHOs/IPAs should help address this but this requires resourcing, as does clear agreement on
who is responsible for standards setting.
Thus quality systems in primary care will need upgrading in the following realms
o
National source of clinical evidence relevant to NZ primary care
o
Clinical governance at the practice level which is supported by appropriate and
consistent structures and processes across the PHO as a whole
o
Further development of standards of structure and process at practice level and
PHO levels to assure the above and within which are
o
A broader range of quality performance indicators especially focused on patient
access to care, especially for the disadvantaged/high disparities, with an associated
broad range of appropriate incentives, not only financial but also altruistic and
consistent with professional values.
The final consideration is whether such a medical home would be acceptable to patients and the
community. While the Group Health experience has been generally positive from the patient
perspective, their different demographics from NZ and the cultural differences in access to and
utilisation of medical care may mean the Medical Home is less acceptable and offers fewer gains in
this country. Given that demographics and culture differ across our nation, only by implementing the
Medical Home will it be possible to determine what works and what does not. It will require
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engagement and involvement with patients and community in system design to obtain the necessary
buy in.
Summary
The Group Health Medical Home offers many opportunities for NZ general practices to develop their
in-practice care to meet the future needs of our community and patients. Even in regions where
primary care development does not facilitate a Medical Home, there are elements that can be
implemented by practices presumptive of reasonable practice business functionality. While the
concept of standardised care might seem to reflect a “McDonaldization” of health careiv, if it
facilitates variation based on patient need (not want) and permits a reduction in health care
disparities, then it must be considered and trialled in practices in this country.
This report was funded by GPonline Ltd.
References:
i
The Influence of National Culture on New Zealand’s Innovation Outcomes. Tony Smale. © Forte Business
Group Ltd 2008 Available online at
http://www.forte-management.co.nz/resources/5-tonys_dissertation.pdf.ashx
ii
Ibid
iii
Aiming for Excellence Standards for New Zealand General Practice (3rd edition) 2009. RNZCGP. Available on
line at http://www.rnzcgp.org.nz/assets/documents/CORNERSTONE/Aiming-for-Excellence-2009-includingrecord-review.pdf
iv
McDonaldization: “occurs when a culture possesses the characteristics of a fast-food restaurant”
http://en.wikipedia.org/wiki/McDonaldization
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About the Authors
Ruth and Jim Vause set up Redwoodtown Doctors, Blenheim in 1985 after 5 years in rural general
practice. The practice now has 5 doctors, 3 nurses, 4 administration staff and one practice assistant.
Both Ruth and Jim have been involved in quality work in general practice for 15 years and together
they have visited some 110 practices around New Zealand as RNZCGP Cornerstone Assessors and
practice consultants.
Ruth is the practice manager at Redwoodtown Doctors, a previous member of the executive of
PMAANZ and been involved in the development of the RNZCGP Aiming for Excellence Standards.
Jim has been a general practitioner for 35 years. A past president of the RNZCGP, he is currently Te
Akoranga o Maui appointee to the RNZCGP executive, Chairperson of the New Zealand Guidelines
Group and a founding member of the National Screening Advisory Committee. Evidence based
medicine, disease screening and information technology in health are his interest realms, as is health
care quality, having been on the Epiqual and QIC national quality committees while internationally
he was Website Medical Editor for WONCA (the world organisation of GPs) for two years, a previous
NZ rep to WONCA and has provided advice on quality in primary care to McMaster University and
the Ontario College of Family Physicians. Kai Tahu and Kati Mamoe are his iwi.
For further information email to vauses@gmail.com or phone 021 30 1649
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