It’s the Systems! L. Gregory Pawlson MD, MPH

Executive Vice President NCQA

Core Presentation

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Why Focus on Systems? • IOM reports: “To Err is Human” and

“Crossing the Quality Chasm” – both reports provided substantial evidence on critical

importance of systems (including evidence from other areas (aviation)

• Evidence from a few RCT’s (measurement benchmarking and feedback) and studies with reasonable experimental design that systems appear to positively influence quality and efficiency

• Research showing variance on process outcome measures explained more by site/group than individual clinician

• Studies of Shortell, Wagner, Roblin and others on importance of structure and organization

3Physician Practice Connection and Patient Centered Medical Home

Focus on systems allows change from “blaming” individual clinicians for mistakes and

shortfalls to actions related to improving systems to facilitate

clinician success

4Physician Practice Connection and Patient Centered Medical Home

Wagner Model for Effective Prevention and Chronic Illness

Care

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Moving from models to practice

• Provide additional evidence of linkages between use of systems using structural measures, and both quality and efficiency process-outcome measures

• Development of reliable and valid tools for evaluating systems presence to use for both research and implementing practice change

• Create structural measures that are directly actionable and are free from major bias and confounds at physician office practice “microsystems” level – Sample size– Attribution– Need for risk adjustment

• Link adoption and use of systems to payment

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Patient Centered Medical Home

Delivery System Design

ClinicalInformationSystems

DecisionSupport

Self-ManagementSupport

What’s Included?(Infrastructure)

How Much Used?(Extent)

What Functions?(Implementation)

Evidenceand Scoring(Verification)

PPC

Wagner Chronic CareModel Community

Support

Overlap in Content of PPC-PCMH-CCMOverlap in Content of PPC-PCMH-CCM

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Office SystemsDecision Support

Information Technology Delivery System Design

Patient Support

Implementing and Evaluating PCMHImplementing and Evaluating PCMH

Inputs

Evaluation

Programs

Tools

PatientExperience

of CareMeasures

(CG-CAHPS)

Clinical Process &Outcome Measures

(inc overuse, resource use)(Recognition programs

and/or group/plan data)

Office Systems

Assessment (PPC)

Patient CenteredOngoing Care

IndividualClinician-Staff

Attitudes, behaviorsand proficiencies

Educational Support

Output

MOC(Boards)

Practice Evaluation Programs

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Linkage of PCMH to Reimbursement for “ongoing” care

Fee Schedule for Visits/Procedures

Payment per patient per month (or per year)

for level of “Patient Centered Medical Homeness”

Pay for Performance- Clinical and Patient Experience