Health Care Transformation

Health Care Health Care TransformatioTransformatio

nn The journey toward a medical The journey toward a medical homehome

in Harlan, Iowain Harlan, Iowa

Don Klitgaard, MD, FAAFPDon Klitgaard, MD, FAAFP

MMC Medical DirectorMMC Medical Director

With Duane Magee, patientWith Duane Magee, patient

Luncheon Panel

Goals of our discussionGoals of our discussion

Process of transformation – what Process of transformation – what have we been doing in past 2+ years have we been doing in past 2+ years to become a PCMHto become a PCMH

Physician experiences with changesPhysician experiences with changes How has this affected the patient How has this affected the patient

experience?experience? What have we learned so far through What have we learned so far through

the process?the process?

Who Are We?Who Are We?Myrtue Medical Center – Myrtue Medical Center –

Harlan, IAHarlan, IA Critical access hospital/rural health clinic Critical access hospital/rural health clinic

system, integrated since 1991system, integrated since 1991 Medical staff – 7 Family Physicians, 1 Medical staff – 7 Family Physicians, 1

Med/Peds, 1 general surgeon, 3 PAs, Med/Peds, 1 general surgeon, 3 PAs, 2ARNPs2ARNPs

Nursing staff – 35, Office staff - 22Nursing staff – 35, Office staff - 22 Main clinic in Harlan, community of 5200 Main clinic in Harlan, community of 5200

in rural Iowa, and 3 satellite clinics in in rural Iowa, and 3 satellite clinics in Avoca, Shelby and Elk HornAvoca, Shelby and Elk Horn

Full scope of practice – Inpatient, ER, Full scope of practice – Inpatient, ER, NH, OB, procedures, clinic coverageNH, OB, procedures, clinic coverage

Harlan, IowaHarlan, Iowa

Harlan, IowaHarlan, Iowa

Myrtue Medical CenterMyrtue Medical Center

Real patients – the Real patients – the Magee familyMagee family

Practice DemographicsPractice Demographics

20,787 active patient e-records20,787 active patient e-records Newborns to 107 year oldsNewborns to 107 year olds Wellness to acute illness to chronic disease Wellness to acute illness to chronic disease

carecare 38,000+ clinic visits in last year38,000+ clinic visits in last year $6.5 million gross clinic revenue$6.5 million gross clinic revenue $159,000 net clinic income$159,000 net clinic income Payors – 39% Medicare, 30% Wellmark Payors – 39% Medicare, 30% Wellmark

BC/BS, 20% other commercial insurers, 7% BC/BS, 20% other commercial insurers, 7% Medicaid, 4% self-payMedicaid, 4% self-pay

Where we started in Where we started in 2005-06 – ripe for 2005-06 – ripe for

practice-level changepractice-level change Interim, then new CEOInterim, then new CEO No clinic managerNo clinic manager Nurses union turmoil – large nurse Nurses union turmoil – large nurse

turnoverturnover Many failed practice improvement projects Many failed practice improvement projects Failed EHR implementation/lost IT staffFailed EHR implementation/lost IT staff Stressed Medical, office, and nursing staffStressed Medical, office, and nursing staff We want to improve and change but we We want to improve and change but we

know that we need help to do it!know that we need help to do it!

The Imperative to The Imperative to ChangeChange

According to the Future of Family Medicine ReportAccording to the Future of Family Medicine Report::

“ “unless there are changes in the broader unless there are changes in the broader healthcare system and within the specialty, healthcare system and within the specialty, the position of family medicine in the the position of family medicine in the United States may be untenable in a 10-20 United States may be untenable in a 10-20 year time-frame, which would be year time-frame, which would be detrimental to the health of the American detrimental to the health of the American public.”public.”

Do we really have to Do we really have to change?change?

““You don’t have to change, survival You don’t have to change, survival is optional”, C. Edwards Demingis optional”, C. Edwards Deming

Enter the TransforMed Enter the TransforMed NDP…NDP…

What is it about? (vision)What is it about? (vision) What changes are we making What changes are we making

through it? (process) through it? (process) What are we learning through the What are we learning through the

process? (outcomes)process? (outcomes)

TransforMED MissionTransforMED Mission

The mission of TransforMED is The mission of TransforMED is to lead and empower family to lead and empower family physicians in implementing the physicians in implementing the new model of carenew model of care

The TransforMed ProjectThe TransforMed Project

AAFP-funded National Demonstration AAFP-funded National Demonstration Project - $8 million initial investmentProject - $8 million initial investment

Applied January 2006Applied January 2006 Selected April 2006 Selected April 2006 24 month project began June 2006 24 month project began June 2006

and ended May 31, 2008and ended May 31, 2008 Evaluation period will end December Evaluation period will end December

20082008

National Demonstration National Demonstration ProjectProject

36 sites from around the country 36 sites from around the country were selected to study the new were selected to study the new model.model.

These practices were randomly assigned to These practices were randomly assigned to

one of two groupsone of two groups• 18 facilitated practices will engage in a transformative 18 facilitated practices will engage in a transformative

process to fully implement a new model of careprocess to fully implement a new model of care• 18 self directed practices will be provided the information 18 self directed practices will be provided the information

to implement the model of care in a self directed manner.to implement the model of care in a self directed manner.

Facilitated PracticesFacilitated Practices

Henry Ford Family Medical Henry Ford Family Medical Center - TroyCenter - Troy

West Shore Family MedicineWest Shore Family Medicine

Myrtue Medical Center - Myrtue Medical Center - Harlan, IAHarlan, IA

MHS Primary Care, Inc.MHS Primary Care, Inc.

Hailey Medicine ClinicHailey Medicine Clinic

Family Practice PartnersFamily Practice Partners

LifeScape Medical AssociatesLifeScape Medical Associates

Hays Family MedicineHays Family Medicine

Central Oregon Family Medicine, Central Oregon Family Medicine, PCPC

James J. Meyer, M.D., PCJames J. Meyer, M.D., PC

The Doctor's OfficeThe Doctor's Office

Cranford Family PracticeCranford Family Practice

Harbor of HealthHarbor of Health

Stephen J Veit, MDPC – Stephen J Veit, MDPC – Cherokee, IACherokee, IA

Trinity Clinic WhitehouseTrinity Clinic Whitehouse

Family Health Center of Joplin,IncFamily Health Center of Joplin,Inc

Ramona G. Seidel, MD LLCRamona G. Seidel, MD LLC

Family Medicine, Geriatrics and Family Medicine, Geriatrics and WellnessWellness

Goals of the NDP Goals of the NDP EvaluationEvaluation

To generate and disseminate new To generate and disseminate new knowledge about the process of knowledge about the process of practice transformation.practice transformation.

To evaluate and compare the effects To evaluate and compare the effects of two transformation approaches of two transformation approaches (i.e., facilitated vs. self-directed) on (i.e., facilitated vs. self-directed) on practice and patient outcomes.practice and patient outcomes.

Goals of the NDP Goals of the NDP EvaluationEvaluation

To determine the effect of the New To determine the effect of the New Model (PCMH) implementation on Model (PCMH) implementation on the following:the following: Patient outcomesPatient outcomes Patient-centered carePatient-centered care Staff/physician working Staff/physician working

relationships relationships Financials of the practice Financials of the practice

What we agreed to:What we agreed to: Implementation - Implementation - all aspects of the New all aspects of the New

Model during the 24 monthsModel during the 24 months EvaluationEvaluation – staff/patient satisfaction – staff/patient satisfaction

surveys, clinical/chart reviews, financial surveys, clinical/chart reviews, financial reviews, etc.reviews, etc.

DisseminationDissemination – lessons learned during the – lessons learned during the NDP will be shared in many venuesNDP will be shared in many venues

Staff commitmentStaff commitment – lead physician and – lead physician and staff member for learning collaboratives in staff member for learning collaboratives in KC, monthly phone conferences, ongoing e-KC, monthly phone conferences, ongoing e-mails, on-site visits with TransforMed staffmails, on-site visits with TransforMed staff

What we received in What we received in return:return:

A worthy vision – gets to the heart of A worthy vision – gets to the heart of medicine, especially FM/primary caremedicine, especially FM/primary care

Practice Enhancement Facilitator – 1 Practice Enhancement Facilitator – 1 for each 6 practicesfor each 6 practices

Exposure to best practice ideas in all Exposure to best practice ideas in all areas of practice redesignareas of practice redesign

Ongoing consultant supportOngoing consultant support Some specific IT product assistanceSome specific IT product assistance

Patient experience – Patient experience – PCMH conceptPCMH concept

Concept make sense?Concept make sense? Importance to patients, families, Importance to patients, families,

employers, communityemployers, community

Myrtue Medical Center Myrtue Medical Center Clinics ProjectsClinics Projects

Where to start? Where to start? How do you eat an elephant….?How do you eat an elephant….? Prioritized by :Prioritized by :

Easy wins/low-hanging fruit – needed Easy wins/low-hanging fruit – needed practice at team design and needed practice at team design and needed confidence-buildersconfidence-builders

Largest obstacles to improved care earlierLargest obstacles to improved care earlier What made sense in the big picture – What made sense in the big picture –

some projects built on otherssome projects built on others

Our transformation Our transformation process – where and how process – where and how

to startto start Team building/Vision sharing – soft, but Team building/Vision sharing – soft, but

criticalcritical Main focus in the first 2-3 monthsMain focus in the first 2-3 months

Honest Self-Assessment – brutal reality Honest Self-Assessment – brutal reality checkcheck First monthFirst month

Goal development/Timeline settingGoal development/Timeline setting Started thinking about and discussing right Started thinking about and discussing right

away, details gradually took shape over the away, details gradually took shape over the first 3-4 monthsfirst 3-4 months

Our transformation process Our transformation process - Overview of the projects- Overview of the projects

Projects – the work starts in earnestProjects – the work starts in earnest Staff empowerment/redesign Staff empowerment/redesign Advanced Access SchedulingAdvanced Access Scheduling EHR Implementation – Oh, the pain……….EHR Implementation – Oh, the pain………. Clinic process review Clinic process review Chronic Disease Management Chronic Disease Management Clinical decision support/Point of care Clinical decision support/Point of care

reportsreports Wellness integrationWellness integration

Myrtue Medical Center Myrtue Medical Center ClinicsClinics

Current ProjectsCurrent Projects Staff redesign/empowerment – Staff redesign/empowerment –

Daily nursing huddles – easy/effectiveDaily nursing huddles – easy/effective Lead nurse selection and development Lead nurse selection and development Clinic manager – critical missing elementClinic manager – critical missing element Immunization nurse – improved efficiencyImmunization nurse – improved efficiency Health coaches/Chronic Disease Health coaches/Chronic Disease

Management nurses – manage registries, Management nurses – manage registries, proactive care; proactive care;


Current ProjectsCurrent Projects Open Access/Advanced Access SchedulingOpen Access/Advanced Access Scheduling

Accurately matching supply with demandAccurately matching supply with demand Started with a 2 week internal study of Started with a 2 week internal study of

Supply – hours available by provider by daySupply – hours available by provider by day Demand – appointments requested by provider and as a Demand – appointments requested by provider and as a

wholewhole Gave us an accurate picture of problem times – Gave us an accurate picture of problem times –

supply/demand mismatches supply/demand mismatches Made changes in scheduling to help – opened more Made changes in scheduling to help – opened more

open slots on busiest days/times, added evening hoursopen slots on busiest days/times, added evening hours Continual reassessment and revision process Continual reassessment and revision process This can now drive good decisions on need for more This can now drive good decisions on need for more

staff as well as how to handle holidays, vacations, staff as well as how to handle holidays, vacations, crunch times bettercrunch times better

Patient experience - Patient experience - accessaccess

Open/Advanced accessOpen/Advanced access Extended hoursExtended hours Saturday hoursSaturday hours Impressions of access changes?Impressions of access changes?


Current ProjectsCurrent Projects EHR implementation/use – go live was 2/07EHR implementation/use – go live was 2/07

HUGE change for all, especially Med StaffHUGE change for all, especially Med Staff Planning, planning, more planning crucial – 2 Planning, planning, more planning crucial – 2

yrsyrs Many benefitsMany benefits

Intraoffice e-messagingIntraoffice e-messaging E-prescribingE-prescribing Real-time documentation with templatesReal-time documentation with templates Expanded access to informationExpanded access to information

Allows for a new level of population-based care, Allows for a new level of population-based care, point of care improvements, etcpoint of care improvements, etc

An extremely useful tool, but not an endAn extremely useful tool, but not an end

Patient experience – Patient experience – TechnologyTechnology

EHREHR E-prescribingE-prescribing Change in patient experience – Change in patient experience –

laptops, information access, rxslaptops, information access, rxs


Current ProjectsCurrent Projects Clinic process review - started asking many Clinic process review - started asking many

hard questionshard questions How does information flow around our office? How How does information flow around our office? How

should it flow in an efficient, effective medical should it flow in an efficient, effective medical home? Who does what process, and should they?home? Who does what process, and should they?

rx refills, NH questions, phone messages, lab resultsrx refills, NH questions, phone messages, lab results How can we as a Medical staff make group How can we as a Medical staff make group

decisions to make our staff’s days (and patient’s decisions to make our staff’s days (and patient’s care) better?care) better?

Standardized care - templates, flow sheets, standing Standardized care - templates, flow sheets, standing ordersorders

Moving towards true team care of patients – Moving towards true team care of patients – especially those with chronic diseasesespecially those with chronic diseases

Not easy, but big returns in efficiency!Not easy, but big returns in efficiency!


Current ProjectsCurrent Projects Chronic Disease Management /Population Chronic Disease Management /Population

Management/Health CoachesManagement/Health Coaches Diabetes, asthma, hypertension, CHF……who?Diabetes, asthma, hypertension, CHF……who? First had to develop disease registries – not easyFirst had to develop disease registries – not easy Foster a true team approach to care – OUR team of Foster a true team approach to care – OUR team of

physician, nurse, scheduler, health coach (as opposed physician, nurse, scheduler, health coach (as opposed to calls from insurer’s nurse, CMS reviewer, etc.)to calls from insurer’s nurse, CMS reviewer, etc.)

Allows flexibility – simple reminder calls to lengthy Allows flexibility – simple reminder calls to lengthy face-to-face interventions, either planned or face-to-face interventions, either planned or opportunisticopportunistic

Health Coaches to monitor populations of patients – Health Coaches to monitor populations of patients – get them in for needed care, provide proactive get them in for needed care, provide proactive interventions, help give patients more empowerment interventions, help give patients more empowerment and controland control

HUGE potential for improved careHUGE potential for improved care

Patient experience – Patient experience – Chronic disease Chronic disease

managementmanagement See value with family, as employer?See value with family, as employer?


Current ProjectsCurrent Projects Clinical decision support/Point of care (POC) Clinical decision support/Point of care (POC)

reports – 2008?reports – 2008? Offers enhanced disease registry functions not Offers enhanced disease registry functions not

available in EHRavailable in EHR POC reports based on EHR data run through a POC reports based on EHR data run through a

protocol engine protocol engine Single page reportSingle page report Makes visits much more productiveMakes visits much more productive Easily identifies needed careEasily identifies needed care Can delegate which things nursing can do by Can delegate which things nursing can do by

standing order and which a physician should standing order and which a physician should discuss with the patientdiscuss with the patient

When paired with CDM, much potential for When paired with CDM, much potential for large improvements in patient/population care large improvements in patient/population care quicklyquickly

However, another level of technology – However, another level of technology – cost/interface barrierscost/interface barriers

Patient experience – Patient experience – Point of care remindersPoint of care reminders

Would you like this?Would you like this? See benefits as patient?See benefits as patient?


Current ProjectsCurrent Projects Financial reviewFinancial review

Individual physician and group finances Individual physician and group finances evaluatedevaluated

Offer insights into possible areas of Offer insights into possible areas of improvement improvement

Highlights the need for ongoing dialogue and Highlights the need for ongoing dialogue and education of the medical staff about business, education of the medical staff about business, billing and coding issuesbilling and coding issues

Emphasizes the underlying inherent conflict in Emphasizes the underlying inherent conflict in many physicians between the business of many physicians between the business of medical practice and the practice of medicine – medical practice and the practice of medicine – “just let me take good care of my patients”“just let me take good care of my patients”


Current ProjectsCurrent Projects Office Redesign – in processOffice Redesign – in process

Satellite clinic remodelsSatellite clinic remodels Plans for major clinic overhaul to optimize Plans for major clinic overhaul to optimize

care under the PCMH model care under the PCMH model Wellness integration – in processWellness integration – in process

MMC funding/leading community Wellness MMC funding/leading community Wellness Center project – open late 2009Center project – open late 2009

Will offer many opportunities to encourage Will offer many opportunities to encourage wellness and integrate into our practicewellness and integrate into our practice

Patient experience – Patient experience – WellnessWellness

Impressions from a parent, school Impressions from a parent, school administrator, individualadministrator, individual

Continuing toward a Continuing toward a PCMHPCMH

Future ProjectsFuture Projects Website enhancement/Patient portalWebsite enhancement/Patient portal

Scheduling and refill requestsScheduling and refill requests Electronic bill payElectronic bill pay E-visits/e-mail communicationE-visits/e-mail communication Secure lab resultsSecure lab results Collect PMH on-lineCollect PMH on-line

Referral tracking – “Trudy”Referral tracking – “Trudy” Enhanced communication with Enhanced communication with

hospitals/specialistshospitals/specialists Kiosks in office – check-in, update Kiosks in office – check-in, update

demographics, enter symptoms, instant claims demographics, enter symptoms, instant claims adjudication……adjudication……

The list keeps growing! The list keeps growing!

Patient experience – Patient experience – Website, etcWebsite, etc

Would you use and anticipate other Would you use and anticipate other to also?to also?

Our transformation Our transformation processprocess

Ongoing assessments – metricsOngoing assessments – metrics Metrics, common in business, are largely unused Metrics, common in business, are largely unused

in most smaller practicesin most smaller practices Wait times, staff satisfaction, patient Wait times, staff satisfaction, patient

satisfaction, billing/coding reviews and satisfaction, billing/coding reviews and improvements, individual physician and practice improvements, individual physician and practice level financial assessmentslevel financial assessments

Very helpful Very helpful internallyinternally to identify opportunities, to identify opportunities, gauge process change effectivenessgauge process change effectiveness

If not understood completely and used If not understood completely and used punitively, will derail progress – measuring punitively, will derail progress – measuring complex processcomplex process

Provider, Practice, & NDP Comparison on Wait Time: Practice 6March, 2008

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How would you rate length of time waiting during today's visit?

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Provider, Practice & NDP Comparison, Time With Provider: Practice 6March, 2008

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4

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Provider, Practice, & NDP Comparison, Overall Experience: Practice 6March, 2008

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Myrtue Patient Experience Comparison

July, 2007 to March, 2008

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Satisfaction Wait Time Satisfaction Time With Provider Satisfaction Overall Exp.

Patient Experience Questions

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Patient Experience ElementsNDP Average Comparison

July, 2007 - March, 2008

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March, 2008

Practice NDP Practice NDP

June, 2007

So………what have we So………what have we learned?learned?

(at MMC and in the NDP)(at MMC and in the NDP) Change is Change is hardhard and slow and slow

Transformation on many levelsTransformation on many levels of practices – culture changeof practices – culture change of physicians – personal changeof physicians – personal change of patient expectationsof patient expectations

Practices not used to Practices not used to system-level system-level changeschanges

Personally, I think this will be a 3-5 year Personally, I think this will be a 3-5 year process, even with a motivated, unified process, even with a motivated, unified practice with adequate resourcespractice with adequate resources

What have we learned?What have we learned?

Relationships matterRelationships matter Practice’s capacity for change and ability Practice’s capacity for change and ability

to follow through is heavily dependent on to follow through is heavily dependent on strong relationships within the practicestrong relationships within the practice

Need to build and foster strong Need to build and foster strong relationships on all levels to be successful relationships on all levels to be successful with changeswith changes

Especially important at times when Especially important at times when practice under much stress – i.e. EHR practice under much stress – i.e. EHR implementationimplementation


Medical practices are extraordinarily Medical practices are extraordinarily complex complex Small changes often have large impactsSmall changes often have large impacts Large, difficult changes may be Large, difficult changes may be

necessary but have small impacts overallnecessary but have small impacts overall Change management is an essential Change management is an essential

skill that practices need to be skill that practices need to be successfulsuccessful Eidus’ theorum of change difficultyEidus’ theorum of change difficulty


Leadership is KeyLeadership is Key Need strong leaders in all areasNeed strong leaders in all areas

Physician/mid-levelPhysician/mid-level Clinic manager/nursingClinic manager/nursing Administration/financialAdministration/financial IT systemsIT systems

If not all on the same page, ability to If not all on the same page, ability to make changes hampered or haltedmake changes hampered or halted


Transformation has to happen on the Transformation has to happen on the personalpersonal level also level also Is a gradual change from physician-Is a gradual change from physician-

centered thinking and office practices centered thinking and office practices to team-based, patient-centered careto team-based, patient-centered care

This is just as hard as (or harder than ) This is just as hard as (or harder than ) the practice-level process changesthe practice-level process changes


Technology has great potential, but Technology has great potential, but several problems limit it’s current several problems limit it’s current usefulness and widespread usefulness and widespread implementation.implementation. lack of interoperabilitylack of interoperability ExpenseExpense amount of resources and energy needed amount of resources and energy needed

to make things work togetherto make things work together


PCMH is more than the sum of its PCMH is more than the sum of its individual partsindividual parts

Measurements (NCQA, etc) are Measurements (NCQA, etc) are important and get at many parts of important and get at many parts of the PCMH, but not the full essencethe PCMH, but not the full essence

Medicine is art in addition to scienceMedicine is art in addition to science Patients want healing, not just Patients want healing, not just

diagnosing or curingdiagnosing or curing

The old model of care The old model of care doesn’t make sense in the doesn’t make sense in the

PCMH contextPCMH context Coordinated, not just episodic careCoordinated, not just episodic care Proactive, not just reactive careProactive, not just reactive care Emphasis on achieving and Emphasis on achieving and

maintaining wellness, not just maintaining wellness, not just treating illnesstreating illness

Team-based careTeam-based care Comprehensive careComprehensive care We need high tech We need high tech andand high touch high touch

The Case for The Medical The Case for The Medical HomeHome

Many current national Many current national trends align well with the trends align well with the

PCMH model PCMH model Emphasis on Emphasis on qualityquality and and transparencytransparency

Patients, employers, CMS, payors, health systemsPatients, employers, CMS, payors, health systems Emphasis on Emphasis on patient-centered carepatient-centered care

Convenient, timely, patient-friendlyConvenient, timely, patient-friendly Emphasis on Emphasis on technologytechnology – not just in our – not just in our

practices but in individual patient’s livespractices but in individual patient’s lives Google Health, Revolution.com, WellMark/UHC, Google Health, Revolution.com, WellMark/UHC,

etc. will change health care perceptions and etc. will change health care perceptions and expectationsexpectations

Emphasis on Emphasis on practice redesign/innovationpractice redesign/innovation PCPCC, TransforMed/AAFP, IHIPCPCC, TransforMed/AAFP, IHI

Emphasis on Emphasis on wellnesswellness promotion/disease promotion/disease preventionprevention

Where does that leave Where does that leave us?us?

BuyersBuyers of care should find what they of care should find what they have been buying unacceptablehave been buying unacceptable

ProvidersProviders of care should find it of care should find it unethical and even immoral to continue unethical and even immoral to continue to provide episodic, uncoordinated careto provide episodic, uncoordinated care

PatientsPatients should be at the center of a should be at the center of a redesigned system that needs both:redesigned system that needs both: TransformationTransformation of medical practice of medical practice ReformationReformation of payment for care to of payment for care to

support itsupport it

How do the participating How do the participating practices feel about the practices feel about the

TransforMed NDP?TransforMed NDP? Extremely excited and encouragedExtremely excited and encouraged Much harder than we thought Much harder than we thought

initiallyinitially Absolutely worth it and imperative!Absolutely worth it and imperative! Privileged to be part of the processPrivileged to be part of the process

How can stakeholders How can stakeholders help?help?

Support/fund pilot projectsSupport/fund pilot projects Need to include PCPCC blended payment modelNeed to include PCPCC blended payment model

Continued fee-for-serviceContinued fee-for-service CDM feeCDM fee Additional P4P incentivesAdditional P4P incentives

Support those working to affect changeSupport those working to affect change Funding educational efforts, learning collaborativesFunding educational efforts, learning collaboratives Tap into national/state primary care academiesTap into national/state primary care academies

Support innovators/early adoptersSupport innovators/early adopters Technology improvementsTechnology improvements Support for PCMH concept in your sphere of Support for PCMH concept in your sphere of

influenceinfluence Support Primary Care education Support Primary Care education

In medical schools, primary care residenciesIn medical schools, primary care residencies

Website ResourcesWebsite Resources Patient-Centered Primary Care Collaborative – Patient-Centered Primary Care Collaborative –

www.pcpcc.net TransforMed – TransforMed – www.transformed.com AAFP – AAFP – www.aafp.org Center for HIT – Center for HIT – www.centerforhit.org

Institute for Healthcare Improvement – Institute for Healthcare Improvement – www.ihi.org

Iowa Healthcare Collaborative – Iowa Healthcare Collaborative – www.ihconline.org

Myrtue Medical Center – Myrtue Medical Center – www.myrtuemedical.org

Why I want to see the Why I want to see the PCMH succeed in the U.S.PCMH succeed in the U.S.

Contact informationContact information

Don Klitgaard, MDDon Klitgaard, MD 1220 Chatburn Avenue1220 Chatburn Avenue Harlan, IA 51537Harlan, IA 51537 712-755-5130 (PCMH)712-755-5130 (PCMH) 712-579-1911 (cell)712-579-1911 (cell) [email protected]@myrtuemedical.org

Documents

Health Care Transformation