National Alliance for Physician Competence€¦ · Web viewA Brief Word about Scenario Planning 3. An Overview of the Process: Summit I and Summit II 4. Your Next Assignment 6

Physician Accountability for Physician Competence • Summit I & II Summary

TABLE OF CONTENTS

Executive Summary......................................................................................................2

A Brief Word about Scenario Planning.......................................................................3

An Overview of the Process: Summit I and Summit II..............................................4

Your Next Assignment..................................................................................................6

National Alliance for Physician Competence.............................................................7

Draft Table of Contents for Good Medical Practice...................................................8

Action Plan for Good Medical Practice Table of Contents.....................................11

Expanding the Alliance...............................................................................................12

Mapping Competence Activities................................................................................13

Strategies for Working Through Resistance to Change.........................................14

A Model of a Future System – to stimulate discussion...........................................15

Objectives for Future Summits..................................................................................28

Timeline........................................................................................................................29

Addendum A: The Scenarios.....................................................................................31Techno Community AllianceData CacophonyThe Federal Tarbaby,Brave New World, Happyhealthcare.com

Questions for Discussion..........................................................................................42

Addendum B: Mostly Likely Scenario ......................................................................43

Addendum C: Ought to Be Scenario.........................................................................47


Executive SummaryWhat will healthcare in the United States be like in the year 2020? and how should physician competence be evaluated and measured within the context of a future US healthcare system?

In March 2005, a group of leaders drawn from a broad cross section of medicine came together for two days in Fort Worth, Texas for Summit I. The focus of this summit was to think creatively about the future of physician self-regulation and to explore the context within which physicians will be expected to demonstrate accountability in the year 2020.

During that summit the participants identified five possible pathways to the future of US healthcare. The goal of this first conversation was to better understand the trends and developments that are influencing society and the healthcare arena in the United States, and to use this deeper understanding to develop stories about what that future might look like. The idea behind developing these scenarios is not to present definitive truths but stimulate debate about how physician competence should be evaluated and measured within the context of a future US healthcare system?

After Summit I these scenarios were distributed to the participating organizations with the goal of stimulating dialog and gathering their feedback.

In December 2005 a group representing the same organizations plus a few additional groups convened in Chicago, Illinois for Summit II. The focus of this summit was to incorporate the feedback generated after Summit I and to dive deeper into the scenarios, explore the implications of these scenarios on various stakeholder groups and to begin to think about possible responses by the healthcare community.

During Summit II participants explored many options for potential responses, began to look at the definition of competence, generated a draft table of contents for Good Medical Practice and generated several models to stimulate further conversation about physician competence in 2020.

Ultimately, the goal of this initiative is to provoke debate and forward movement by the profession to develop solutions to the problem of evaluating and measuring the continued competence of physicians. The primary question driving the creation of these scenarios for convening these summits is: how does the healthcare community determine, measure and assure the public concerning physician competence over the career of the physician?

Ambassador’s Guidebook page 2


Scenario PlanningThe process of creating scenarios to explore the future of physician self-regulation was inspired by the book, Solving Tough Problems, by Adam Kahane. It requires gathering together a group of individuals who consider the instabilities in the present and by looking at the interaction between the most important and unpredictable drivers of the future they then imagine plausible but different futures.

Scenarios imply the future is not fixed but can be shaped by decisions and actions of individuals, organizations and institutions. Scenarios allow people from across organizations to think creatively about the future and to stimulate debate about how to shape that future. The process of building scenarios can be creative because it is only about telling stories, not about making commitments.

One premise about scenario thinking is that the future is not predetermined and cannot be predicted, which means that the choices one makes can influence what happens. The process is also constructive, in that it turns the attention of a group away from the past and the present – where the debate is often mired – toward the future. It shifts a group’s focus from looking for “the solution” to exploring different possibilities, and from the separate interests of the parties to their common ground.

As ambassadors, it is important that you are perceived as being advocates of the process, and not of any particular position or outcome. While at some point in the future we may move to more active discussions about what we want to happen and what we will do, at this point in time, we are simply asking people to engage in an exercise of reflection and imagination. The goal in this first round of dialogue is to build common ground among different perspectives and parties.



The ProcessSummit I: To set some context for developing future scenarios, the session began with a look back over the last 100 years, listing and discussing events from the realms of society, technology, the economy, education, healthcare and politics. Following this exercise, teams generated key list of factors and driving forces that will be relevant over the next 15 years across the landscape surrounding the greater healthcare industry. One hundred fourteen key factors were created. In the next round, different teams were formed to create scenario generation matrices. Each matrix consisted of four possible scenarios based on a variation in two key factors that served as the x and y axes of the matrix. Out of this round thirty-six scenarios were created. Small groups then spent the remainder of the day narrowing the number of possible scenarios to eight and creating narratives for their scenarios. These scenarios were presented back to the large group as stories. This ended the first day of work.

On the second day, four teams worked on the implications that the eight scenarios might have for various subsets of the healthcare community including payers, insurers and employers; educational organizations; licensing, certification and accreditation organizations; providers and professional organizations; and the public sector. Several other teams worked on creating wild card scenarios and another team had the task of condensing the eight existing scenarios down to four.

In the last round of the session, teams worked on the remaining four scenarios and an additional wild card scenario that made the final cut. Another team worked on next steps and a final team examined the role of physician competence over the next 10 to 15 years - across all of the scenarios.

Summit II: In this Summit, participants initially dove deep into the 5 scenarios as a way to explore the implications of these various future states on specific stakeholder groups (patients/the public, payers, physicians, Health Systems, and Medical Education). Once immersed again into these scenarios, participants then began looking at various ways physician competence might be determined, measured and assured in each of these five different possible future states.

Participants then used a lateral thinking activity called a Take Away to see if they could discover and think differently about the regulatory system. This activity challenged participants to think about the regulatory system as it exists now and to list the components of the current system that are essential for it work. They were then asked to ‘take away’ one or several of the essential parts of the regulatory system and challenged to think about designing a system of regulation that works without that essential part.

Both activities, the Take Away and the previous activity, resulted in a handful of possible options for systems to consider – both structure and process – and it allowed all the participants to experience the complexity of the challenge of unifying a large number of medical organizations around a single process. The experience of this complexity lead the participants to explore the idea of creating an Alliance of organizations focused and aligned around the idea that the Healthcare Community can work together to develop the standards by which physicians are educated and practice medicine and by which the public can be assured of physician competence throughout the life of the physician.



This lead to a dialog about defining what competence is – what a good doctor is – and that resulted in several iterations of a statement of competence as well as a first draft of a table of contents for a document tentatively titled, Good Medical Practice. This document was suggested to be used as a stimulus of further conversation with other members of the organizations present and to begin bringing additional stakeholders into the conversation.

To that end, near the end of the session participants developed a list of additional stakeholders to include in the conversation and a plan to hold several additional Summits and invite them to participate.

NOTE: Participants were urged NOT to make decisions about what competence is nor what the process to determine, measure and assure competence will be in the future. They were however urged to explore various options for how the future might play out and what a competence system might look like in any given future.



Your Next Assignment

Be an ambassador of this process

Quell fear by inclusion and non-punitive mode/behavior

Raise awareness and stimulate discussions about competency

Include in leadership’s agenda (use focused tools)

Share feedback



National Alliance for Physician CompetenceNational Alliance for Physician Competence

PURPOSE: Improve patient care by ensuring physician competence

OUR VALUES BEHAVIORS that exemplify our valuesIntegrity TransparencyCommitment to purpose Showing up and participatingEvidence base Use and improveComfort with innovation Plan for unlearningPersonal to organizational Report regularly on governance responseAccountability: Public Include the consumerAccountability: Each other HonestyCollaboration Harmonization

FUTURE ACCOMPLISHMENTS (over next 12 months): Consensus definition of competence Ideas on how to measure competence and drafts of potential models Decide on how to frame the conversations

o Publico Physicianso Organizationso Other health professions

Harmonize the collaborationso Identify ways to reduce burden of measuremento Alignment in measurement efforto Develop alignment in EMRs and learning portfolios



Draft Table of Contents for Good Medical Practice

Public Statement of Definition

Physician competence is a measurable demonstration of skills, knowledge, and behaviors that meet professional standards, is in the best interest of the patient’s health while being empathetic to the patient’s wants in the context of society’s needs as a whole.

The assurance of competence of a physician is a shared responsibility of the individual physician, the entity that grants a legal privilege to practice medicine, the medical profession, and the public.

Table of Contents

I. Medical Knowledge Keeping up to date

o How to measure: CME/CPD Accessing and evaluation information Mastery of practice specific body of knowledge

o How: Continuous certification Awareness of best Practices, guidelines, consensus documents in specific areas of

practice Understanding limits of knowledge

II. Patient Care Assessment Diagnosis Treatment Effective Referral Record Keeping Specialty principles & practice

o Osteopathic principles Access Treatment in emergencies Timeliness Competency in procedures Effective use of resources Pain management End of life care

III. Professionalism



Confidentiality Ethics - “Charter of Professionalism”

o Boundary issues Honesty / Integrity Issues around consent Avoiding discrimination & prejudice Conflicts of interest Dealing x competency of colleagues Substance abuse (proactive discussion) Impact of aging and illness on practice / competency (self and colleagues) Treats of team members with respect Response to profession Response to community Truth in advertising Billing

IV. Communication Listen to patients & respect their views

o How to measure: Patient surveys Providing info to patients, families and others that is understandable Informing patients of errors Effective record keeping Timely & comprehensive discussion with others involved in care Communication with colleagues Transitions in care (end of life, etc.) Timely results to patients Clarity of communication with patients on business & financial issues

V. Systems Based Practice Physician’s Sphere of Control

o Attention to the environment of careo Team worko Participation in CQI / QA / Audito Assures adequate systems to support the quality of your practice & patient

safetyo Clearly defined policies and procedures

Complying with public health reporting Continuity of care across settings Coordination of care issues Understands and works within payment systems Meeting responsibilities associated with working within delivery systems, eg.,

hospitals, nursing homes



VI. Practice-Based Learning Collect and maintain data about their practice Analyze and learn from data collected Improve practice based on what is learned Understand norms / best practices / benchmarks specific to area of practice Seek feedback from patients regarding their expertise with the practice

Other Similar Documents Charter of Professionalism - Good Medical Practices AMA CEJA CMSS Joint Committee ACS Performance-Based CANMEOS 2000 IOM Competency Document AAMC MSOP AAMC Company on GME Australian Version EU Document (referenced by Dole)

Open Issues Best fit for practice Ownership - accountability - where does the buck stop? Public role

Competency discussion How to measure Who is accountable Educator’s role Public role



Action Plan for Good Medical Practice

Table of Contents

Other similar documents

Charter of Professionalism Good Medical Practices AMA CEJA CMSS Conjoint Committee ACS Performance-based… CANMEDS 2000 IOM Competency document AAMC MSOP AAMC Compact on GME Australian version EU document (referenced by Dale)

Action Plan

1. Find some to synthesize: similar documents and identify missing elements (use Picker Initiative)

2. Do first draft document (single writer with small advisory committee and strong public voice)

3. Distribution to broad group of stakeholders for review and comment (iterative process)

4. FSMB adopts policy5. FSMB encourages stakeholder adoption6. FSMB maintains document until Alliance is established



Expanding the Alliance

Current plus leapfrog (BSNs) and 1-3 public (AARPs + CMS) (consider ½ day orientation for newly added members at next summit)

Future objectives: expansion to non-physician providers

All Stakeholders(consider tiering this group in terms of priorities and urgencies)

Public AARP Cons union National Association for Women & Children National Cons League AFL-CIO

Insurance Companies

GME Reg Dir

Legislators

Employers NFIB CHC Bsns Consortia

Public Citizen

CAC

“Players” in physician standard setting and performance measurement

Expertise in ethics

Coalition for Phys Enhancement



A Map of Physician Competence Activities


Alliance for Physician

Competence

Defining Competence Picker/NBME - Patient Centered Care IOM Producers AHRQ - Multiple Efforts Citizen’s Advisor Council

Implementation NICHQ - Pediatrics Remediation/Assessment Programs

Coalition of Physician Enhancement Stepping up to the Plate

Specialty Societies Disclosure Group AHIP/ AQA CMS Voluntary Reporting AOA Clinical Assessment ABIM Performance Improvement Tools P4P

Bridges to Excellence Leapfrog

IHI - Microsystem Change IPIP (RWS - Primary Care)

Tools to Assess/Measure Competence ABMS / AGIM ACGME NBME - Center for Innovation AHRQ PCPI

Standards in Edu/Training AOA Council on Post MD Training AAMC Institute for Improvement AMA Initiative on Transforming Med Education ABMS MOC Conjoint Committed on MCE JCAHO Health Professions Training LCME ACGME - Competencies

Data on Performance National Quality Forum AMA Physician Consortium Data Aggregation Efforts Health Information (IT) Community RAND Medical Groups/Systems

Real Time Models Health Plans Hospitals VA Council of Accountable Physician Practices

International UK IAMRA HME (outcome based - GMER)


Strategies for Working through Resistance to Change

Stakeholder Strategy1 Individual physician Grandfathering

Buy-in by two-way communication from a trusted source

Overcome uncertainty of licensure loss2 Physician organizations HoD (AMA, AOA, FSMB, etc.)3 Boards, specialty ABMS vs Not: Need to solve if we are to

differentiate in rolling out4 State legislature/License

Board Cycle on when Practice Acts up National licensure buy-in (car model): need to

assure cash flow as competency ongoing evaluated5 Payors Show positive value (= quality/cost) so they don’t

create their own duplication6 Residents/med students Student debt

Workforce issues in rural and small facilities7 IMG organizations We need to address globalization especially

specialties that no touch (NAFTA, CASTA, China)



A Model of a Future System(to stimulate discussion)

A Model for Defining, Assessing and Monitoring Physician Competence in 2020:

A Thought Experiment

A Synthesis of Creativity Exercises at the Physician Accountability for Physician Competence Summit II

December 8-9, 2005

The model presented in the following pages was developed as a thought experiment during the second Physician Accountability for Physician Competence Summit in December 2005. The group that developed this model was given an assignment by InnovationLabs (the facilitators of the Summit) to create a new system for determining, assessing and monitoring physician competence in 2020 that looks different from the qualification systems that are in place today. The purpose of this assignment was to stimulate new thinking and new conversations, not to make recommendations for change. This model has not been validated, tested or endorsed by any individual or organization associated with the Summit. Instead, our purpose in presenting this model in further detail is to foster further conversations.

Assignment for the Reader:As you explore this model on the following pages, identify ways in which this system addresses challenges associated with transparency, portability, validation of competence, and physician currency. Also identify gaps – ways in which this system does not address these issues and others that may occur to you.

Most importantly, as you read through the description of this hypothetical system, what other ideas, discoveries, insights or questions come to mind?

We encourage you to share these insights and questions with us or with your colleagues.


“Educators”

“Regulators”

Physician’s Career Pre Med

Med School

GM

EPracticing


We will begin our description of this hypothetical system for physician competence with an exploration of a new regulatory system.

The largest change in this model from 2005 is the introduction of a National Certification Agency for Boards. This organization defines national standards and competencies for physicians, and certifies Specialty Certification Boards. It is the Specialty Boards in this model which certify physicians to practice medicine. This certification will be limited in scope, however, so that a physician will only be able to practice medicine within his or her specialty. Over time physicians will be able to expand or change their specialty through the recertification process (see below).

The State Licensing Board is responsible for issuing licenses to practice medicine. These boards will meet certain national criteria for licensing which will allow a physician licensed in one state to practice medicine anywhere in the US. This license will be valid for a limited time, and the re-licensing process will require that a physician demonstrate competence.


“Regulators”

National Certification Agency for

Boards

SpecialtyCertification

Board

StateLicensing

Board


In this thought experiment, we decided that the three major educational bodies, the LCME, the ACGME and the ACCME, should coordinate their efforts in an Accreditation Oversight Alliance.

This organization would work closely with the National Certification Agency to define standards and competencies for physicians. These standards and competencies would then be rolled out into the medical education system from Pre-Med programs through Graduate Medical Education and even Continuing Medical Education. These changes will also be reflected in all examinations, including the MCAT.


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“Educators”

“Regulators”









Pre Med

Med School

GME









National

Certification

Agency for

Boards

Accreditation

Oversight

Alliance

LCME

ACGME

ACCME

Standards &

Competencies

Standards &

Competencies


In order for competency to be assured in practicing physicians, certain competencies should be sought out as early as the Pre-Med years. Students applying to Medical Schools should expect to have a high GPA and as strong a resume as ever. The MCAT will also be required, although some of the focus of the exam may shift to include measures of competencies.

Drug screening and Criminal Background Investigations (CBI) will become standard for Med School applicants. Moreover, these applicants will be screened for favorable (and demonstrable) behaviors that will suit medical practice in 2020, and they will be required to demonstrate strong skills with Information Technology.




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Pre Med

Med School


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GPA

CBIDrug Screens

Resume

MCAT

Behavior

IT Skills


As we mentioned above, the evaluation criteria for Med School students in 2020 will reflect the same standards that are used to evaluate practicing physicians. Students will be monitored for both quality and behavior. Physicians in 2020 must not only be technically proficient, they must also demonstrate qualities and skills like strong ethics, teamwork, communication and leadership.

While in Medical School, students will begin their Learning Portfolio. This portfolio will include everything from competencies and behaviors they have demonstrated, to evaluations from peers and patients, to insights and “near-misses” they have had. This portfolio becomes one of the key tools for measuring competence.

In order to move on to residency, students must pass USMLE Modules 1 and 2 (COMLEX), and pass the Clinical Skills 1 exam. (Clinical Skills 2 is introduced later in the physician’s career.)




Physician’s Career



Med School



GME










USMLE Mod 1 & 2/COMLEX

Clinical Skills 1Evaluation Portfolio


When a student enters Residency in 2020, she is granted a “Training License” from the State Licensing Board. This means that the student is NOT a physician until becoming certified in a specialty and fully licensed by the State Board.Throughout GME, the student’s evaluations on quality and behavior are submitted to the Specialty Board. During this time, the students build their portfolios as well.




“Regulators”



Physician ’ s Career



GME












Evaluation

Portfolio

Specialty

Certification

Board

State

Licensing

Board



Training License


Once a student finishes GME in 2020, he will apply for certification in a specialty. Among the criteria for granting certification will be the student’s GME evaluations and portfolio.

Once the Specialty Certification has been issued, it will be sent to the State Licensing Board. This certification allows the physician to practice only the medicine within his given specialty. A greater scope of practice will require additional certification.




“Regulators”



Physician ’ s Career



GME












Evaluation

Portfolio

Specialty

Certification

Board

State

Licensing

Board


The State Licensing Board in 2020 will consider a Specialty Certification as necessary but not sufficient for licensure. The State Board will examine several other criteria, including drug screens and a CBI. Once the physician has been licensed, both the license and certification will be sent to the physician’s hospital for credentialing. Once the physician has been credentialed, she becomes a practicing physician.






Practicing



“Regulators”






Board

StateLicensing

Board



Hospital

Credentialing


Board Certification must be renewed regularly in 2020, perhaps every two years. This renewal is stringent. The key component of the physician’s Maintenance of Certification (MOC) is his portfolio. The portfolio includes his knowledge base (demonstrated) and a wide range of data that has been collected, including practice data, peer reviews, patient evaluations, and outcomes data. Credentialing information is also included in the MOC. The physician must pass a test of his knowledge to renew his certification (unless perhaps his data is so strong that he places out).






Practicing



“Regulators”






Board

StateLicensing

Board



Hospital

Credentialing



















Portfolio

Practice

Outcomes

Data

Test

MOC

Knowledge

Peers

Patients


At some points in her career, a physician may choose or be required to take the Clinical Skills 2 exam. This exam is required if the physician wishes to change or expand her Specialty Certification. Some physicians may choose to take this exam to pursue new interests, or to expand their practices. Other physicians may be required to take this exam because their practice data indicates that they are dealing with medical issues in their patients that fall outside of their Specialty Certification.






Practicing



“Regulators”






Board

StateLicensing

Board





















MOC



CS2


Periodically, the data being collected in a physician’s portfolio will indicate some kind of problem. Academic or clinical problems will be referred to the Specialty Board. The Specialty Board will evaluate the circumstances and send the physician a Development Plan (if necessary) to bring the physician’s knowledge or skills up to standards.

Behavioral problems will be referred to the State Licensing Board. The State Board will recommend a behavior change or take further punitive actions.






Practicing



“Regulators”






Board

StateLicensing

Board
















Problems



Dev. Plan

Academic & Clinical

Problems

Behavioral

Problems


The system that was designed during this thought experiment was highly successful by at least one definition – it looks very different from the system that is in place today! While the system as a whole has a number of challenges associated with it, the purpose of the thought experiment was to look at the problem from a new perspective in order to (hopefully) gain some new insight.

No one expects the system in 2020 to look anything like this model, but if this description has prompted new thoughts or questions or insights, then the experiment has been a success! Please share your thoughts and keep the conversation going.








“Educators”

“Regulators”





















Pre Med

Med School

GME

Practicing





































































“Educators

”

“Regulators

”

Physician

’s Career


















Pre Med Med School GME Practicing










































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National

Certification

Agency for

Boards

Accreditation

Oversight

Alliance

LCME

ACGME

ACCME

GPA

CBI

Drug Screens

Resume

MCAT

BehaviorIT Skills

USMLE Mod 1 & 2/COMLEX

Clinical Skills 1

Evaluation Evaluation

Training License

PortfolioPortfolio

Portfolio

Practice

Peers

Patients

Outcomes

Data

Knowledge

Specialty

Certification

Board

CS2

Test

MOC

Problems

Hospital Credentialing

State

Licensing

Board

Dev. Plan


Objectives for Future Summits

Summit I (in 4-6 months) Objectives Broaden the base including the public and physicians

o As homework, advance the issues deemed “not ready for primetime” and use next summit to finalize definitions, structure and process

o Begin to merge structure and process discussion (??) Develop a timeline and strategy Strategy for communication and buy-in (may include identifying “must complete issue”

and less urgent pieces)o Physicianso Other potentially resistant groups

Iteration of GMP and competency utilizing ambassadorial feedback Define structure, governance, financing of “the Alliance” Invitees: The Alliance and Alliance Expansion

Summit II (in 9-12 months) Objectives Either a super-summit or a series of regionals Bring “all stakeholders” and potentially resistant groups to provide feedback, criticism

and join in as collaborators Allay fears Identify champions and landmines Invitees:

Everyone in some format (group leans toward regionals and allows dialogue, voice, listening)

Flexible and inclusive Integrate into existing meetings

Summit III (in 15 months) Objectives Pick up the pieces or put the pie together! Modify the strategic plan based upon super summit feedback Defuse the landmines Re-evaluate product based on summit feedback Identify pilots for implementation Interface with EMR

How they influence competence How competence should influence EMR Developing EMRs that enhance data availability for physician portfolio



Timeline

Action/Deliverable Notes Date0100

Meeting frequency Two summits (One summit has results of public input)

Collating info Time for orgs to discuss (6

months) Maintaining momentum

0110

Meeting for public input Do we need a better aligned plan or blank slate?

Include in our meetings vs “public” meeting

0120

Planning identifies other parties to invite to summits

0130

Orientation for those we bring in

2-4 hours for attendees Focus groups? Young physicians? Students? Residents?

0140

Info/Feedback on our groups

Needs to be digestible

0150

Further development of Alliance

Form committee to work on feasibility and report

0160

Produce document for wide distribution after Summit 4

0170

Make available products (tomorrow—end of December)

Talking tools

0180

Schedule two summits 2/1/06

0190

Coordinate focused mini-summits

Public Students, residents, young

physicians Data by June/July summit 20-30 people each

3/1/06

0200

Nat(?) All for Phys Competence Committee Form

Meet Report Based on work of group 4

2/06-3/066/06

0210

Develop and tweak products

Best practices Definition of competence Systems and process

4/06-5/06



Action/Deliverable Notes Date0220

Develop presentation for Fed Annual Meeting

4/06

0230

Provide feedback pathway

1/06

0240

Summit With orientation for new attendees (2-4 hours)

Outline white paper

06/06 07/06

0250

Summit Educational Marketing Consider for action “Public” consumption “Final” dev of white paper Define talking points Alliance white paper Principles, not action plan

11/06 12/06

0260

Discussions with organizations

Let them know we are talking about measuring competency and say they need to discuss

Principles, not details0270

Make summit materials available two weeks ahead of time





Addendum A: the Scenarios

The five scenarios contained in the following pages were developed at the summit and subsequently refined into stories that can stand alone when read by people who did not attend the session. These scenarios are not intended for wide distribution, nor to be seen as final in any way. Brief descriptions of each are provided below.

The first scenario, Techno Community Alliance, depicts a healthcare system where information technology provides a platform for the provision of safe and effective health care. Using its collective resources, the healthcare community develops standards for the collection of data and for how those data are used to hold practitioners accountable for demonstrating competence. Data are collected and stored in a national database, and national standards for performance are developed.

The second scenario, Data Cacophony, depicts a world where the healthcare community is unwilling to face realities. Public demand for change in the way healthcare is delivered generates much discussion but little coordinated response. Chaos emerges.

The third scenario, The Federal Tarbaby,

The fourth scenario, Brave New World,

In the happyhealthcare.com scenario, skyrocketing healthcare costs combine with increased public dissatisfaction with the system to prompt dramatic change in control of the healthcare dollars. Patients become true consumers of healthcare services, basing buying decisions on value and cost. In response, the healthcare community turns to continuous quality improvement as the basis for how they deliver care.

Addendum A: The Scenarios page 32


Scenario 1: Techno Community Alliance

The first scenario, Techno Community Alliance, depicts a healthcare system where information technology provides a platform for the provision of safe and effective health care. Using its collective resources, the healthcare community develops standards for the collection of data and for how those data are used to hold practitioners accountable for demonstrating competence. Data are collected and stored in a national database, and national standards for performance are developed. 2005-2010 The US healthcare system is besieged by escalating costs, public dissatisfaction, decreasing labor pools, and misaligned incentives encouraging over-utilization of procedures.

Providers become increasingly disgruntled because payers are implementing pay for performance measures as a means of lowing costs and improving quality. Each payer had its own set of measurement criteria, and the administrative work involved with collecting the data necessary to meet the varied requirements are increasingly burdensome and overwhelming. Few providers are willing to invest in electronic medical records in part because of the expense involved but mostly because there are no assurances that IT systems would be interoperable and that the investments will pay off financially.

The federal government intervenes by developing standards for an IT infrastructure that would allow health professionals to share data electronically. The initiative receives positive public reaction but has mixed results within the healthcare community, due in part to provider concerns about lack of funding and mandates. Little progress is made in developing standards for performance measurement.

Recognizing that interoperability could be possible by 2020, a consortium of the health care community – health care professionals, hospitals, insurers, educators, regulatory bodies, peer review organizations, and professional associates – meet and agree to collaborate to develop national standards for measuring practitioner performance. After many months of dialogue, the group releases standards for performance measurement that are applicable across professions. The standards are predicated on development of a central data repository containing millions of cases that would facilitate a number of improvements in quality. It is proposed that the database be controlled by the consortium; however, public concerns about transparency and public accountability prompt significant debate about this recommendation. The provider community prevails but only after agreeing to report to a federally appointed public oversight agency.

2010-2015: Healthcare costs continue to increase, and physician and nursing workforce shortages coupled with an aging population continue to negatively impact public access to care. Demand for more affordable healthcare choices spurs insurers to begin reimbursing non-traditional healthcare services, such as telehealth services or services provided by non-physicians or alternative medicine providers. Businesses and insurers begin to outsource healthcare services to countries like India and Dubai, which offer state of the art facilities and US trained health professionals at a fraction of the cost in the US. Use of telehealth services increases, with many of the telehealth providers located outside the US.



Budget deficits, the rising costs of health care and the aging of America take their toll on Medicare, as the system appears to be headed for insolvency. State-based Medicaid programs also appear to be going bankrupt. The percentage of Americans who are uninsured increases annually. Bowing to public pressure, Congress introduces legislation that would create a national healthcare system; the public is generally supportive of the bill but businesses and special interest groups prevail and the initiative is narrowly defeated.

Meanwhile, acceptance of the consortium’s performance measurement standards slowly gains ground, particularly among multi-state payers and healthcare systems. These progressive healthcare systems are using the standards to measure the performance of healthcare teams rather than individual practitioners. Use of EMRs is also slowly increasing, although an effort by the federal government to mandate their use is blocked by the provider community in part due to the mandate being unfunded. However, the Center for Medicare and Medicaid implements such requirements of its participants.

2015-2020: CMS’ mandated use of EMRs, coupled with the influx of newly educated, techno-savvy healthcare professionals, and reduced costs in hardware and software, results in exponential growth in the use of EMRs. Providers are capturing performance data using EMRs and transmitting the data to the central repository. The data are used by the healthcare community and the government to develop standards of care, disease management profiles and to perform outcome analysis. Trend analysis across graduate and undergraduate education for physicians, nurses and allied health personnel are available to the government and the public. Assessment tools are developed to evaluate the performance of the healthcare system. All data are available to the public for use in selecting providers.

By 2020, patients are using health smart cards that contain their medical history and which can be updated from their providers’ health networks via the internet. Patient care is managed using evidence-based protocols, and EMRs are used at the point of care. Significant advances in patient safety are gaining ground, as hospitals and healthcare institutions employ technology such as optic scanning to confirm patient identity or electronic prescription and order entry systems that are integrated with EMRs.

Medical advances resulting from genomics and nanotechnology are less costly and are increasingly available to all patients, not just to the affluent. Healthcare providers use computers to help identify possible diagnoses and suggested methods of treatment based on patient data entered. Patients have immediate access to their own individual health information as well as provider performance. Pay for performance is the norm.



Scenario 2: Data Cacophony 2020

SUMMARY: This scenario depicts a world where the healthcare community is unwilling to face realities. Public demand for change in the way healthcare is delivered generates much discussion but little coordinated response. Chaos emerges.

2005-2010

It is 2005, and the medical delivery system is under tremendous pressure to improve the quality and safety of care being provided to the American public. Costs are skyrocketing, there has been little improvement in the rate of medical errors occurring, and both patients and practitioners are becoming increasingly frustrated and disillusioned.

Information technologies such as electronic health records (EHRs) are cited as offering opportunities both to significantly reduce costs and improve quality. However, providers are reluctant to implement EHRs because they are expensive and no standards are in place to ensure interoperability across systems. Provider groups, licensing boards, the health professions, federal and state governments, and the payer community can not agree on either basic IT standards or data sets necessary to develop such standards.

Growing budget deficits, fueled in part by escalating healthcare costs, force states and the federal government to cut back in funding for social programs. Although the government is encouraging the use of EHRs, neither private insurers nor federal or state governments have the funds to support investment in them. With no indications that interoperability will be a reality any time soon, EHR use declines and in fact falls well short of predictions.

2010-2015: Insurers and employers attempt to deal with cost increases by shifting the burden to patients. Incentives aimed at encouraging patients to take more responsibility for their health are implemented. Patients become better educated about the “real” costs of healthcare and the limited value received for dollars spent. More and more patients opt for health savings accounts, and public interest in personal health records spikes.

Put in the position of having to “value shop”, patients ask for performance data on healthcare providers but the lack of uniformity in standards for quality comparisons make access to meaningful information impossible. Frustrated at having to pay high prices for care that they perceive as unsatisfactory, patients increasingly turn to non-physician providers who offer less expensive – but often unproven – means of treating illness. They also turn to the internet, where health care entrepreneurs are offering low cost medical care via the internet. They also increasingly turn to the international community for healthcare services, which offer state of the art facilities and US trained doctors at a fraction of the costs for similar services in the US. Entrepreneurs find ways to capitalize on the public’s search for more accessible healthcare by using the internet as a means of providing services. There is little control over the quality of care being provided to patients.

An increasingly competitive market, coupled with a frustrated public and little agreement on what constitutes quality medicine, results in a erosion of trust between patients and their providers. Legislators respond by implementing more regulatory interventions, resulting in even more punitive and complex accreditation and licensure processes.



2015-2020: As the public becomes more value-conscious, it increasingly recognizes the importance of early intervention. Research into genomics and nanotechnology begin paying off with the development of new diagnostics and therapies that allow patients to anticipate what diseases they are susceptible to. Patients begin to see reductions in health expenses in exchange for improved health practices. However, these incentives, while intended to give patients greater personal control over their risks, in fact increases the divide between the wealthy and low-income, since the latter group lacks education, access to technology, and the money to take advantage of new diagnostics and therapies. In addition, patients experience decreased access to care resulting from a growing shortage of health professionals coupled with the changing healthcare needs of the US population brought on by the “graying of America.”

Healthcare organizations are collecting performance data on their network providers but the environment is so unfriendly that no one is willing to collaborate on establishing national standards, making it impossible to conduct meaningful research regarding the validity of performance measurement schemes. Attempts by various providers to make data available for quality improvement purposes are frustrated by privacy concerns and the legal profession’s demand that any data be fully discoverable for the purposes of litigation. In several areas of the nation, instances of manipulation of data to increase market share begin to surface. In many of these instances, this manipulation of data actually was responsible for worsening rather than improving care.

This toxic state leaves a serious trust vacuum between patients and the entire healthcare community over the quality of American healthcare. By 2020, multiple data sets, many conflicting, are required at each patient encounter. Numerous entities including CMS, specialty boards, state licensing boards, and payers had so many different standards that there was no way to validate even the basic definition of quality of care or physician competence.

As a result, quality improvement stagnates, costs continue to rise; the profession remains fragmented and continues to lose the trust of the public.



Scenario 3: The Federal Tarbaby

2005-2009: Elected leadership at both the state and federal level feel increased public pressure to deal with a number of domestic crises, including sky-rocketing healthcare costs and increasing numbers of individuals who are uninsured, continued threats of terrorism, continued loss of jobs to international markets, and a faltering economy.

Seeking ways to reduce spending on healthcare, the government develops a blueprint for how patient data systems could be structured and connected to allow for improved data sharing. Negotiations with provider communities around their concerns regarding funding and privacy take place in an attempt to gain buy-in to the government’s patient data blueprint. The parties reach agreement on trade-offs, the most important being if the providers agree to voluntarily participate in a reporting system the government will make changes to the system to reduce inefficiencies.

An epidemic of medical errors prompts an immediate and harsh public call for greater patient safety. The federal government steps in to establish a system of total reporting with the analysis of data being made available by the government to the public via the internet. As part of this process, Congress passes legislation that abolishes the current tort system and replaces it with a no-fault system similar to Australia’s.

Bolstered by public calls for greater patient safety, the federal government mandates the use of electronic records to improve disease management and reduce medical errors. Providers struggle to find the dollars necessary for installing such systems and integrating them into their practices.

Concurrently, the amount of dollars spent on alternative medicine by US citizens continues to increase, fueling opinions that the public sees no value in the existing delivery system. Taking advantage of this, payers (both government and private) offer incentives to patients that encourage disease prevention. Providers lobby payers to change the reimbursement system to reward disease prevention.

By 2009 a tremendous amount of provider performance data has been reported to a national database and there is a push to develop practice guidelines nationally.

2010-2015: The economy goes into a tailspin. Corporate America pushes the burden of health care costs to employees, resulting in an increasing number of uninsured Americans. A call for universal coverage generates the political will to develop it. The difference this time around is that the government already has the data it needs. A multi-stakeholder committee is formed in which the public, the government and the profession collaborate to develop a plan for universal healthcare coverage. Many aspects of the current system would be nationalized, including oversight of accreditation and licensure.

The coalition is fragile, dependent upon each party trusting the other. However, it holds together and produces a plan that all stakeholders could support. The plan calls for the creation of a national office of secretary of health to oversee the elements of the new federal health plan. A “Medicare for all” system emerges that guarantees minimum coverage for all Americans, but the option to purchase private insurance in the open market is also retained. The system encourages preventative health, relies on the



national standards developed through years of data collection to drive disease management, and depends heavily on non-physician providers to triage primary care needs of patients. The role of physician changes from independent practitioner to team leader.

This new model for reimbursing care results in the forging of new alliances within the healthcare community, and a coalition of medical organizations representing all the health professions is formed.

By 2020, regional integrated delivery systems are responsible for monitoring the competency of practitioners and providing standards by which teams of health professionals are evaluated. These systems employee virtually all the physicians and other health professions, held together by information systems.

Care is less expensive and more readily available for everyone, but only those who can afford the private health insurance are ultimately assured of receiving high quality care.



Scenario 4: Brave New World: Healthcare in the year 2020

Bill Smith logs on to mydoc.com, types in his symptoms and is immediately directed to a nurse practitioner who is on-call in India. Comparing Mr. Smith’s symptoms against a set of clinical guidelines recently released by the International Alliance of Certified Internet Practitioners, the nurse directs Mr. Smith to go to the Health Depot two blocks from his house for some diagnostic work. There are Health Depots on every corner, much like convenience stores. Mr. Smith arrives at the Health Depot, approaches a self-serve health kiosk, inserts his personal health record security card, enters his biographical data and is assigned a processing number. He sticks his finger into an opening on the kiosk and has blood drawn for a blood test, then walks to the next room, enters his processing number in an automated x-ray machine and gets a chest x-ray.

Before he leaves, he directs the Health Depot automated teller to transmit the results of his tests to the nurse practitioner in India. Within an hour the nurse in India has reviewed the results and, based on the Bill’s expressed symptoms, he recommends Bill see his local physician. He sets up an appointment with Bill’s physician, then before moving onto the next patient inquiry, transmits the results of the tests and a summary of his interaction with Mr. Smith to Bill’s physician.

When Mr. Smith arrives as his local physician’s office, he gives his personal health record to the physician’s nurse, who inserts the card into the office’s electronic health record system to update Bill’s office record. His physician has already reviewed the data sent to her by the physician in India. Bill’s physician tells him that the data, blood test, chest x-ray, etc shows that Bill has a cancer and is a candidate for surgery. The physician pulls up a website containing outcomes data on cancer centers of excellence around the country to show where Bill can go to be treated. The list includes performance data for the Centers for the specific cancer that Bill has, which he uses to select where he wants to be treated. The doctor makes the arrangements for Bill.

Two days before Bill is to be admitted to for surgery, he pulls up the hospital’s website and prints off his pre-authorization and admission verification forms. Upon arriving at the hospital, he inserts his personal health record into the registration kiosk, enters his pre-authorization number, and completes check-in. He is then shown to his room, and within two hours has had a conference with the treatment team that will be handling his case.

When Bill gets out of the hospital he receives an email request from the hospital asking him to complete a patient evaluation form. His The feeds back into the system.

The huge challenge here is who has the responsibility for licensure and the investigation of all the players? Who has the tort liability for this? In such a highly technological system, who pays for the initial setup?

The plusses of this are the cost constraints and wide access. There would be strict standards of care. Medical education is interesting. The med students could have access to any doctor in the system to learn about whatever topic they were interested in.

The downside would be that the physicians would need the technology for this. Some people might choose to opt out of the system because they are either technology averse or couldn't afford it.



Monitoring standards would also be quite tricky.

Scenario 5: Happyhealthcare.com

In this scenario, skyrocketing healthcare costs combine with increased public dissatisfaction with the system to prompt dramatic change in control of the healthcare dollars. Patients become true consumers of healthcare services, basing buying decisions on value and cost. In response, the healthcare community turns to continuous quality improvement as the basis for how they deliver care.

In an effort to bring spiraling healthcare costs into control, employers and insurers begin using health savings accounts as a means of shifting healthcare costs to patients and encouraging patients to be more responsible for both their health as well as for dollars they spent on healthcare. As patients become more comfortable with the increased responsibility, they begin demanding better resources – like personal health records and better provider comparison data – for use in making decisions about their healthcare needs. Portable health insurance becomes the norm, and patients that were once completely oblivious to the cost of healthcare become very shrewd shoppers for value-driven care.

Faced with such dramatic shifts in how healthcare dollars and decisions were being managed, providers respond by collaborating to redesign the delivery system using continuous quality improvement as the foundation for change. This collaboration is aided when the federal government publishes national standards for information technology as a means of facilitating better data collection and sharing.

Federally funded regional partnerships between providers, patients and employers are formed to develop and manage performance data collection for use in accreditation, credentialing, licensure and public education. Performance standards are developed and implemented at a regional level and monitored nationally by the federal government for significant variances across pre-determined public health indicators. Reports are used by the region collaborations to make improvements to care.

Healthcare remains a market-driven industry, with both traditional and non-traditional providers competing for patients’ healthcare dollars. While this model benefits the majority of Americans, it does result in a greater divide between the haves and have-nots.

As patients become more knowledgeable consumers of healthcare, they increasingly demand more public investment in health prevention, disease management, and stronger incentives for research and development to meet public health goals. A whole industry of watch-dogs, product testing and consumer reporting companies develop to support patients in their new role as healthcare decision makers and payers.

Teaching institutions benefit from the reformed delivery system because they can track and measure their students more efficiently across the continuum of practice. Public calls for more and better applied research are possible because of the available performance data, and providers benefit from more customized lifelong learning offerings.



Licensing boards begin holding practitioners accountable for outcomes in patient care, rather than for meeting minimum standards. With the help of the provider community, practitioners whose patient outcomes are in question are identified early and receive appropriate intervention and remediation; liability insurance providers agree to cover this practice because it reduces the risk of malpractice suits. The public is not initially supportive of this shift, fearing it is an attempt by providers to “protect their own” in the face of change, but through education, research and most importantly, improved patient care, public trust increases.

There is a level of provider attrition because some practitioners don’t measure up to agreed-upon performance standards. However, the emphasis on continuous quality improvement and collaboration across provider groups facilitates systems-based practice and team-based care, so that the attrition in providers is manageable. Because of the reliability of the data, there is also better risk management.

Initially, these changes prompt a push-back from the health professions – and in particular the physician community. Many long-time practitioners, perceiving a loss of control and autonomy, resent the philosophical premises upon which continuous quality improvement and consumer driven care are predicated. In particular, the notion of being compared against one’s peers is perceived as very threatening. These perceptions, while not enough to prevent the revolution from occurring, does hamper progress.



Questions for Discussion

The purpose of these scenarios is to allow people and organizations to see how certain actions and decisions can positively or negatively impact the future. When presenting the scenarios to your governing board, please solicit feedback and discussion on the following questions:

1. Given the values of our organization, what is the right thing for us to do in each scenario?

2. What should we do to improve patient care in each scenario? 3. What are the implications of each scenario for our organization?4. Who else should be included in this discussion about evaluating and measuring

competence?



Addendum B: Most Likely Scenario

Relative to what we thought was likely, we see significant data collection and use, an increase in technology use. One of the issues out there is how to protect individual privacy. There would be a new payer system which would not be employer based. We wondered it if it would be universal healthcare coverage.

Driving this is a number of trends which include increasing government intervention, alternative medicine which is not necessarily going back to the 1800s but covers anyone who is not being assisted by the traditional medical community at present.

We see an increase of evidence-based medicine, pay for performance, tort reform, public health and disease prevention, patients taking self-responsibility, as well as the change in our demographics which is that we are an aging population.

We also considered national licensure as opposed to state licensure. We looked at ways of looking at working with physicians such as with punitive or remedial means.

Looking at this scenario from the various constituencies we came up with this list of characteristics.

Sultan: Here is where I thought we should be going. There are some things that are compulsory and others that are noncompulsory. The public looks at these people managing all their care and have no control on any of this. They only have control of elected officials. To measure competency we need a common body from the non-compulsory groups of people. We want to create a physician competency board.

Comment: The specialty boards are not compulsory. They are in fact voluntary. They are of the profession themselves.

Addendum B: Most Likely Scenario page 43



QuickTime™ and aTIFF (Uncompressed) decompressor











Addendum B: Ought to Be ScenarioWe began with two points: The patient needs to be at the center. The patient is someone who needs anything from our system; this is not an illness based system. On the outside of this circle we have anyone who provides services to this patient. We want to make sure that we don't undercut innovation. We had a 3 or 4 layer system. Under the patient core, we have a logical and trustworthy control of resource allocation.

Two things that this resource control would include is to use availability to push back on patients. If patients choose to engage in risky behaviors then resources would be less available. There is a lot of depth here.

We also want to provide a certain level of safety. We think that providers should not be able to provide services that do not meet basic levels of safety. There are a lot of models for how to do this. It could be voluntary, government mandated and others.

We compared it with auto safety. There are a lot of options when you buy a car but you cannot buy a car without seat belts or tires that meet safety requirements. The system should make informational resources available for discretionary choices. We think we need infrastructure standards that are common to the system.

Q: We've seen that a lot of the information on the web is incorrect. How do we deal with that? A: We didn't deal with this directly, but like our car metaphor, there are a lot of sources of information out there. You probably can't control all the information but you can be sure that there is plenty of rich unbiased information available.

We assume there will be some process and we don't know what that is. We need to define a set of collective resources whose allocation is managed in a logical trustworthy manner. One of the patient-centered system is that you can't have it unless the patients have access to resources.

Q: Did you consider the UK's system?A: We didn't. But there are probably other national systems that would be helpful to study.

It was nice not to have to deal with reality. Maybe the next group gets to do that.

Addendum C: Ought to Be Scenario page 47







