Implementation of Patient Centered Concepts In a VA Medical Center to Improve Quality Outcomes - Research Paper Example

? Implementation of Patient Centered Concepts in a VA Medical Center to Improve Quality Outcomes Executive summery Although the United States healthcare costs per capita are among the highest in the world, statistics show that a significant portion of the healthcare provided is redundant or ineffective. Moreover, a major portion of costs goes towards administrative costs. Despite the fact that one in three individuals under the age of 65 were uninsured at some point in 2007 and 2008, the situation is so dire considering the significant deficit and deep recession. Consequently, President Obama and a majority of the congress are attempting to close the gap in health insurance through a combination of public and private programs and incentives. A starting principle for this effort is that cost must be contained for the insured populations to free up funds to partially or fully pay for the uncompensated care pool, without reducing the quality of care. One of the most significant obstacles to improved patient care at a reasonable cost is the relative lack of real-time access to current comprehensive patient medical information, which is easily retrievable for patients, health care providers and healthcare payers. To impact the quality of US healthcare providers and healthcare updated and shared information with all stakeholders in a timely and effective manner to not only ensure universal access to quality data, but also to extend essential information to key clinical decision makers. While some small-scale regional efforts to capture and leverage this information are underway, the healthcare industry as a whole requires encouragement to adopt and better utilize information technology (IT) in both the near term and the long term (Earp et al., 2008). Additionally, government agencies could and have begun to facilitate this greater adoption of technology by considering a number of alternatives: Work with industry to develop standards for medical records, including content, terminology, interoperability, and code sets implemented as a network of networked electronic health records, identify higher-cost disease management and clinical treatment areas and prioritize IT investments in areas that show the most likelihood of reduction to regional variation in cost per patient and medical outcome. Problem Background The U. S. has the most advanced healthcare delivery of most countries in the world. Per capita expenditure totaling to thousands of dollars annually, and more of her GDP is ranked relatively higher on healthcare than most countries in the world, at 18.5 percent of GDP in 2007. It has the most sophisticated teaching hospitals and medical research centers in the world yet it is not ranked in first position worldwide. Additional factors significantly impacting how healthcare expenditure is allocated include a few diseases that comprise the bulk of healthcare expenditures. Significant variations in spending can also be mapped by regional, race and socio-economic status. Even diet has a major impact since the US also happen to be the most obese nation on the planet and in essence, just throwing money at the problem will not fix it. Similarly, Information Technology has been applied in very sophisticated ways to deliver better care, but not in a way that makes the cost and decisions (as to when and how to deliver it) more efficient and transparent. This paper highlights one case study that demonstrate how health concepts can improve health quality (such as in a VA medical center), and how it can serve as a key component of effective healthcare delivery by creating the necessary data framework for practicing evidence-based medicine (EBM). EBM is gaining traction among providers for two major reasons: firstly, its promise as a tool to help contain continually rising healthcare costs and, secondly its potential to dramatically improve healthcare quality. Implementation of Patient centered Concepts According to Conway et al (2006), the healthcare industry in the United States is operating at a level of quality and efficiency below the desired standards of patients’ healthcare professionals. The majority of concerns focus around access to care, quality of care, prevalence of incorrect medical diagnoses and rising costs. Furthermore, a solution for business problems can be attained by adopting return on investment (ROI) compared to value produced by addressing the problem and determining which solution is provided. Statistically, a considerable number of expensive health conditions accounted for almost half the total health care expenses, which was mostly chronic conditions and patients with multiple chronic conditions with up to seven times as much as patients with only one chronic condition. About a quarter of the total annual US expenditure on healthcare is spent on ineffective or redundant care. Healthcare premiums have arose by more than half within a decade for family premiums. The U. S. spends more money per capita on healthcare than any other country. Similarly, organizational costs to acquire and implement electronic healthcare information systems are significantly; particularly to individual medical practitioners as most of the technology solutions currently available are not mature due to the lack of standards and other factors. Cumbersome workflows and ongoing training and maintenance costs are other barriers to acceptance. Misaligned cost burdens for individual practitioners are also an impediment to implementing electronic health information in the current environment. For electronic health records (EHRs) to be fully functional, Electronic Medical Record (EMRs) and clinical information systems (such as computerized provider order entry [CPOE] systems) must first be put in place. However, a 2005 study by the Medical Group Management Association showed that less than 10% of physician practices surveyed had a fully implemented EMR. One reason is that while the cost of the EMR system is fully borne by the healthcare provider, the healthcare payer actually recognizes many of the benefits of the EMR system. In addition to these monetary costs, physician productivity is negatively impacted in the short term as new systems and new processes are put in place, and some estimates put the drop in productivity down. While the hope is that these costs are recovered in the long term, the short-term impact should not be ignored and may serve as a barrier to physician acquisition of these systems, not to mention the burden of physician training and running duplicate systems during implementation (Frampton et al., 2008). According Bertakis and Azari (2011), healthcare providers are not the only group associated with rising healthcare spending who require cultural changes. Healthcare consumers, who are not fully practicing wellness and maintenance of care, contribute to healthcare spending inflation. The Collateralized Bond Obligation (CBO) is estimated that healthcare cost for the obese to be higher than for non obese. Smoking, high alcohol consumption, lack of exercise, poor eating habits, and other patterns contribute to higher costs and declining health. Historically, with the exception of children and adults with chronic conditions, most healthcare consumers have not maintained a relationship with a primary care practitioner unless they are initiating an illness appointment. This model of care and level of interaction does not promote healthcare literacy or provide opportunity for reinforcement of prevention messages (Earp et al., 2008). According to Johnston et al., (2006), health care law and bioethics address the delivery of an extremely important, very expensive, and highly specialized professional service rendered in situations of tremendous personal vulnerability. These high stakes are what makes health care so expensive and its dilemmas so compelling. People are advised to attend more closely to the psychological realities of treatment encounters and to the essential ingredients of medical practice and professionalism. Sometimes, it matters fundamentally, even profoundly, that a legal matter involves physicians caring for patients, rather than providers servicing generic consumers. One of the difficulties of envisioning and then bringing about a more patient-centered health law is the fact that the patient is often absent as an active participant in the shaping of law. Much of what is known as health law is common law, shaped by the aims and arguments of litigants and the understanding of judges, and by precedent that was in turn shaped by the aims and arguments of past litigants and the understanding of past judges. Because law is decided by judges who face concrete cases and is practiced by lawyers who serve clients with particular interests, it is fragmented and piecemeal. It tends to focus on the problems and concerns of the people or institutions with the money to hire lawyers and to pursue litigation or influence legislators and regulators. Medical ethicist Larry Churchill, in Money-Driven Medicine, provided this summary of the present state of affairs: The current medical care system is not designed to meet the health needs of the population. It is designed to protect the interests of insurance companies, pharmaceutical firms, and to a certain extent organized medicine. It is designed to turn a profit. It is designed to meet the needs of the people in power. The classic 1901 case of Hurley v. Eddingfield provides a clear example of a clear case of a doctor who was found to owe no duty to treat a dangerously ill individual even if, as alleged, the doctor had been the patient’s family physician, the doctor’s fee was tendered, no other physician was procurable in time, and the patient relied on the doctor’s services and the patient died. Within the academic health law, it has become commonplace to consider health law as involving four principal concerns: “quality, autonomy, access, and cost.” Ideally, high quality is supreme respect for autonomy, wide access, and low cost. A focus on the experience of patients being ill and seeking care is neither mandatory nor assumed, nor is it embedded in the study of health law as now generally conceived, which tends to focus on industry and public policy concerns. Shifting the focus to the patient in the study of health law opens up greater possibilities for the practice of health law to be more attentive and responsive to patient experiences (Balik et al., 2011). On the other hand, risk management principles are effectively utilized in many areas of business and government including finance, insurance, occupational safety, public health, pharmacovigilance, and by agencies regulating these industries. Although there are some examples of the use of quality risk management in the pharmaceutical industry today, they are limited and do not represent the full contributions that risk management has to offer. In addition, the importance of quality systems has been recognized in the pharmaceutical industry and it is becoming evident that quality risk management is a valuable component of an effective quality system. The way health care delivery is organized and managed can provide incentives for the delivery of quality health care, as well as address the fragmentation of care resulting from numerous health providers offering services from different, limited specialty perspectives or programme areas (Bertakis & Azari, 2011). At the institutional level, there is a need to adopt measures that respond to the needs of patients, health practitioners and other staff. Effective interventions at the organizational level specifically relate to physical environments; service coordination and continuity of care; multi-disciplinary collaboration and partnerships; patient education and counseling; models of care; incentives for safe, quality and ethical services; and leadership capacity. Providing a conducive and comfortable environment for people receiving health care and for health practitioners, health care environment designed for comfort, safety and functionality, providing access to social, emotional and spiritual support for patients and their families, as well as for staff of the facility; appropriate and flexible visiting policies; risk management policies (i.e. infection control guidelines) that protect the public, patients and staff; and use of waiting rooms and other public spaces within the premises of health care facilities and organizations for opportunistic health education (Hibbard, 2004). Health systems and services have become overly biomedical-oriented, disease-focused, technology-driven and doctor-dominated as Silversin and Kornacki (2000) have found out. There is a need to restore balance in health care including the health system itself. Health care financing mechanisms have not been optimal, pushing provider behaviour towards inadequate care–short consultations, lack of referrals, under- or over-servicing in relation to financial incentives, inadequate case management, and discontinuity of care. Medical education has increasingly concentrated on body systems and disease conditions. The broader and important aspects of cultural context, psychosocial factors, medical ethics, and communication and relational skills, among others, have been neglected. There is a need to put emphasis not only on technical quality but also on the experiential elements of care. Workforce development and policies should be reviewed accordingly. According to Balik et al., (2011), there is little patient and family participation in health care. This is abetted by factors such as low levels of education and health literacy, limited availability and sharing of understandable and culturally appropriate information and education materials, short and hurried consultations, and lack of population health and public health focus of the health system. Specialization and weak referral systems have led to fragmentation and discontinuity of care, both within and between health care institutions, and between the formal health care system and other sources of care, such as support groups and the community. Traditionally, the focus has been the supply side of the health equation the biomedical, technological, provider and delivery system side of health care. It is time to pay more attention to the demand side patients, families, communities and society at large. Case study Centers for Medicare & Medicaid Services—Physician Quality Reporting Initiative 2009 PQRI The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275) made the PQRI (Physician Quality Reporting Initiative) program permanent, but only authorized incentive payments through 2010. Eligible Physicians who meet the criteria for satisfactory submission of quality measures data for services furnished during the reporting period, January 1, 2009 - December 31, 2009, will earn an incentive payment of 2% of their total allowed charges for Physician Fee Schedule (PFS) covered professional services furnished during that same period (the 2009 calendar year). Since its inception in December of 2006, PQRI has served to provide a financial incentive to participate in the voluntary quality reporting program with the primary goals of promoting and supporting evidence-based medicine, increasing the overall quality of care provided under Medicare, and transforming the Medicare program from a passive payer to an active purchaser that rewarded professionals for quality healthcare provision and effective outcomes. As a part of promoting physician participation, CMS worked to develop an automated system that was easy for the participants to access and use. In addition, the system needed to ensure the protection of private healthcare information from inappropriate access, and be able to sort through submitted information and generate reports that would allow CMS to assess the submitted claims and identify those claims that qualified for the bonus payment. Oracle's WebCenter Interaction portal and Oracle's WebLogic Application Server enable “Quality Net,” the CMS PQRI Portal that serves to accomplish this. CMS recently announced more than $36 million in bonus payments to many of the more than 56,700 health professionals who satisfactorily reported quality information to Medicare. The average incentive paid for individual professionals was more than $600, and the average incentive payment for a physician group practice was more than $4,700, with the largest payment to a physician group practice totaling more than $205,700.As participation in PQRI grows and emphasis on patient quality is highlighted over time, bothpatients and providers can benefit. Conclusion When combined, adoption of Healthcare Information Technology, the practice of Evidence- Based Medicine, and the deployment of quality initiatives, tremendous gains can be realized in the healthcare ecosystem. As a matter of fact, they have been successfully deployed in many healthcare settings and have proved to offer great potential to promoting “Meaningful Use of IT.” Additionally, these technologies can reduce healthcare costs and increase the overall quality of patient care by providing access to current, comprehensive healthcare information for both patients and healthcare providers across public and private healthcare settings. While there are potential pitfalls with any new technology and disease management strategy, there is a growing body of evidence that Evidence-Based Medicine can lead to cost savings, better care and better outcomes. According to Bohmer and Lawrence (2008), there are significant challenges to the widespread deployment and adoption of EHRs and there will be resistance on all fronts to the yet-to-be-determined facts yielded from EBM, facts that will be backed by a preponderance of evidence that only a healthcare data grid of the magnitude described above can provide. There are concerns that the decision-making authority - the art of the science - could erode. But the humanity of medicine will not perish, doctors will not become subordinate to a massive artificial brain – the smart in the EBM grid are the practitioners themselves. Patients will not decide they can evaluate all the information and request even more expensive care. Administrators concerned with the bottom-line will not block all subsequent spend on new treatments and technology. Patients and administrators will not become practitioners nor will looking at the data diminish their appreciation or reliance on parishioners; instead, it will make them better consumers and partners in the quest to improve patient care and along the way, as a byproduct to reduce the cost. References Balik, B., Conway, J., Zipperer, L., & Watson, J. (2011). Achieving an exceptional patient and family experience of inpatient hospital care. Cambridge, MA: Institute for Healthcare Improvement. Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine, 24(3), 229-239. Bohmer, R, & Lawrence, D. (2008). Care platforms: a basic building block for care delivery. Health Aff, 27:1336–40. Conway, J., Johnson, B. H., Edgman-Levitan, S., Schlucter, J., Ford, D., Sodomka, P., & Simmons, L. (2006). 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