The Virtual The Virtual Connection: Connection:

Electronic VisitsElectronic VisitsJoseph E. Scherger, MD, MPHJoseph E. Scherger, MD, MPH

National Medical Home National Medical Home SummitSummit

March 3, 2009March 3, 2009

The Holy Grail of Health The Holy Grail of Health Care 2009Care 2009

Cost ReductionCost ReductionQuality ImprovementQuality ImprovementService ImprovementService Improvement

The Secret Sauce for The Secret Sauce for SuccessSuccess

Care becomes Care becomes continuouscontinuous access rather than episodicaccess rather than episodic

Care becomes Care becomes proactiveproactive rather than reactiverather than reactive

Patients become activated for Patients become activated for self-managementself-management

NCQA Recognition as a NCQA Recognition as a PCMHPCMH

Access and CommunicationAccess and Communication Patient Tracking and Registry Patient Tracking and Registry

FunctionsFunctions Care ManagementCare Management Patient Self-Management SupportPatient Self-Management Support Electronic PrescribingElectronic Prescribing Test and Referral TrackingTest and Referral Tracking Performance Reporting and Performance Reporting and

ImprovementImprovement Advanced Electronic CommunicationsAdvanced Electronic Communications

58 y/o female with obesity and diabetes comes 58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and in with symptoms of fatigue, insomnia and

back pain. She has a 15 minute appointmentback pain. She has a 15 minute appointment

HEDIS diabetes measures for this patientHEDIS diabetes measures for this patient::

Percent with an annual retinal exam Percent with an annual retinal exam Percent with one of more glycohemoglobin tests Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests Percent of those having glycohemoglobin tests

showing a level of <8.5 percent (goal <7.0)showing a level of <8.5 percent (goal <7.0) Percent with an annual screening test for Percent with an annual screening test for

microalbuminuria microalbuminuria Percent with two or more blood pressure checks Percent with two or more blood pressure checks

per year per year Percent of those with one or more blood pressure Percent of those with one or more blood pressure

checks having a systolic BP <135 (goal <<130/80)checks having a systolic BP <135 (goal <<130/80) Percent with an annual lipid panel Percent with an annual lipid panel Percent of those with an annual lipid panel Percent of those with an annual lipid panel

showing an LDL level <130 mg/dL (goal << 100)showing an LDL level <130 mg/dL (goal << 100)

Case con’tCase con’t

Other Diabetes Measures:Other Diabetes Measures: Flu vaxFlu vax PneumovaxPneumovax Dental visitDental visit Cardiac screening test?Cardiac screening test? Lab monitoring for side effects of Lab monitoring for side effects of

medsmeds Annual foot examAnnual foot exam Baseline EKG?Baseline EKG?

Case con’tCase con’t

Cancer Screening needs:Cancer Screening needs: Colon- needs colonoscopy (or 3 other Colon- needs colonoscopy (or 3 other

types of screening)types of screening) Cervical- needs pap if last <1-3 years Cervical- needs pap if last <1-3 years

priorprior Breast- needs annual mammogramBreast- needs annual mammogram

Osteoporosis screening and preventionOsteoporosis screening and prevention

Depression Screening and Management Depression Screening and Management

Case con’tCase con’t General health issues:General health issues: Adult TdAdult Td Weight managementWeight management Advance Directives/DPOAAdvance Directives/DPOA Culturally-sensitive careCulturally-sensitive care Patient EducationPatient Education Self ManagementSelf Management Tobacco ScreenTobacco Screen Alcohol screenAlcohol screen Domestic violence screenDomestic violence screen

The Time Problem The Time Problem Time Needed for Time Needed for

Chronic Illness CareChronic Illness Care Time Needed for Time Needed for

Preventive CarePreventive Care Time Needed for Time Needed for

Acute CareAcute Care Total face to face time Total face to face time

for 2500 patientsfor 2500 patients

Ann Fam Med 2005;3:209Ann Fam Med 2005;3:209

Am J Pub Health Am J Pub Health 2003;93:6352003;93:635

10.6 hours a day for 10.6 hours a day for 2500 patients2500 patients

7.4 hours a day7.4 hours a day

4.6 hours a day4.6 hours a day

22.6 hours/day22.6 hours/day

The Ticking Clock The Ticking Clock in the Doctor’s in the Doctor’s

Office:Office:Patients on routine visits Patients on routine visits to their primary doctors to their primary doctors

often have lots of often have lots of questions but not enough questions but not enough time to get good answerstime to get good answers

NY Times Feb. 6, 2007NY Times Feb. 6, 2007

Information Technology Changing Information Technology Changing MedicineMedicine

Patient InformationEHR , All Clinical Data

CommunicationDigital Connection of

Patients with Caregivers

Knowledge Management

and Decision Support Tools

The First Rule of The First Rule of RedesignRedesign

Crossing the Crossing the Quality ChasmQuality Chasm

Care is Based Care is Based on on Continuous Continuous Healing Healing RelationshipsRelationships

New Model of New Model of Medical PracticeMedical Practice

Patient Patient Centered Centered Medical Medical HomeHome

Health Care Becomes Health Care Becomes ContinuousContinuous

Patients Live Their Health and Illnesses Patients Live Their Health and Illnesses Every DayEvery Day

Quality Health Care Offers Continuous Quality Health Care Offers Continuous Access and EngagementAccess and Engagement

Patients Will Drive the InnovationPatients Will Drive the Innovation Patients Will Have Their Medical Records Patients Will Have Their Medical Records Patients Have Access to All Medical Patients Have Access to All Medical

Information – The Return of the Public Information – The Return of the Public LibraryLibrary

Patients Will Communicate Far and Wide Patients Will Communicate Far and Wide for Care for Care

Young Can’t Young Can’t Imagine Life Imagine Life

Without Online Without Online AccessAccess

Associated PressAssociated Press

December 5, 2004December 5, 2004

Why Use E-Visits?Why Use E-Visits?

Improve patient accessImprove patient access Enhance patient educationEnhance patient education Increase patient satisfactionIncrease patient satisfaction Reduce telephone time and Reduce telephone time and

costscosts Can balance risks and benefitsCan balance risks and benefits Competitive advantageCompetitive advantage Transform work scheduleTransform work schedule

Benefits of E-MailBenefits of E-Mail

Visit extender - increased Visit extender - increased communicationcommunication Patients forget questionsPatients forget questions Intimidated face-to-faceIntimidated face-to-face

Enhance participatory Enhance participatory relationshiprelationship

Change service utilizationChange service utilization Behavioral coachingBehavioral coaching

Potential Problems with E-MailPotential Problems with E-Mail

Confidentiality and securityConfidentiality and security Time demandsTime demands MisinterpretationMisinterpretation Inappropriate usesInappropriate uses Digital divideDigital divide

Myths About Patient E-MailMyths About Patient E-Mail

Myth #1: Hackers could read my Myth #1: Hackers could read my patient’s confidential messages.patient’s confidential messages.

Myth #2: It will take more time from Myth #2: It will take more time from my day, and I won’t get reimbursed for my day, and I won’t get reimbursed for it.it.

Myth #3: If I allow patients to e-mail Myth #3: If I allow patients to e-mail me, I will receive a flood of e-mail me, I will receive a flood of e-mail messages.messages.

Myth #4: Patients will ramble.Myth #4: Patients will ramble. Myth #5: I may get sued, and a lawyer Myth #5: I may get sued, and a lawyer

will discover my e-mail messages.will discover my e-mail messages.

The New CommunicationThe New Communication

Interactive Web Site For:Interactive Web Site For: Lab Results And Other DataLab Results And Other Data Arranging Preventive ServicesArranging Preventive Services Chronic Illness CareChronic Illness Care Behavioral CoachingBehavioral Coaching Group VisitsGroup Visits Minor Acute ProblemsMinor Acute Problems

LDL Management May LDL Management May Be Easier With E-MailBe Easier With E-Mail

Family Practice News, July 1, Family Practice News, July 1, 20042004

William T. Lester William T. Lester Randomized Trial at Mass Gen Randomized Trial at Mass Gen

HospHosp Better ManagementBetter Management Fewer VisitsFewer Visits

The Doctor Is OnlineThe Doctor Is OnlineSimply providing a surgeon’s Simply providing a surgeon’s e-mail address nearly triples e-mail address nearly triples the likelihood that a patient the likelihood that a patient will contact the doctor about will contact the doctor about

the surgerythe surgeryNew York Times, Feb. 18, 2008New York Times, Feb. 18, 2008

RelayHealth studyRelayHealth study California study with Blue Cross of California study with Blue Cross of

CaliforniaCalifornia Controlled trial with 5727 patientsControlled trial with 5727 patients Physicians reimbursed $25 per visits Physicians reimbursed $25 per visits

with patients having a $0-10 co paywith patients having a $0-10 co pay Results:Results:

Overall decrease in spending of $1.92 Overall decrease in spending of $1.92 per patient per month for office visits, per patient per month for office visits, $3.69 overall$3.69 overall

Improved patient satisfactionImproved patient satisfaction

Average Emails per patient per week

00.10.20.30.40.50.60.70.8

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43

No. of Weeks Since 1st Office Visit

1000 pts @ 5 min/email ≈ 8 hrs/week/1000 pts1000 pts @ 10 min/email ≈ 16 hrs/week/1000 pts

Time spent on patient email is predictable…

Old ScheduleOld Schedule

First patient at 8 am and 12 First patient at 8 am and 12 patients each half day patients each half day sessionsession

24 patient visits24 patient visits 12 patient phone calls12 patient phone calls Done at 6:30 PMDone at 6:30 PM Patients served -- 36Patients served -- 36

New ScheduleNew Schedule Begin e-mail at 8 am and communicate Begin e-mail at 8 am and communicate

with 15-20 patients.with 15-20 patients. First patient at 9:30. 6 patients/sessionFirst patient at 9:30. 6 patients/session 12 Patient Visits – vary in length from 12 Patient Visits – vary in length from

brief to extendedbrief to extended 4 patient phone calls4 patient phone calls 34 patient e-mails in 2 sessions lasting 34 patient e-mails in 2 sessions lasting

30-45 min. each30-45 min. each Done at 5:30 PMDone at 5:30 PM Patients served -- 50Patients served -- 50

A New Model of Office A New Model of Office PracticePractice

50% More Caring Interactions Each 50% More Caring Interactions Each DayDay

10-12 Unhurried Office Visits Each 10-12 Unhurried Office Visits Each DayDay

Advanced Access – Do Today’s Work Advanced Access – Do Today’s Work TodayToday

Patients Get All the Time They NeedPatients Get All the Time They Need Patients Receive the Excellent CarePatients Receive the Excellent Care

How?How?

An Interactive Practice Website An Interactive Practice Website 40-60% of Patient Needs 40-60% of Patient Needs

Handled Online or by TelephoneHandled Online or by Telephone Electronic Health Records with Electronic Health Records with

Imbedded Knowledge Imbedded Knowledge Management ToolsManagement Tools

Great serviceGreat service

Concierge Care for Concierge Care for Everyone?Everyone?

Fewer Patients per Family PhysicianFewer Patients per Family Physician Continuous AvailabilityContinuous Availability Focus on Comprehensive Care Including Focus on Comprehensive Care Including

PreventionPrevention Enhanced Professional and Patient Enhanced Professional and Patient

SatisfactionSatisfaction Is Concierge Practice the Custom Invention Is Concierge Practice the Custom Invention

that will lead to the Model of the Future?that will lead to the Model of the Future? American Society of Concierge Physicians is American Society of Concierge Physicians is

now the Society for Innovative Medical now the Society for Innovative Medical Practice DesignPractice Design

Make it Affordable Make it Affordable

Greenfield HealthGreenfield Health 9 FPs and IMs Practice in Portland, OR, 2 9 FPs and IMs Practice in Portland, OR, 2

officesoffices Chuck Kilo as Leader (IHI Experience)Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Interactive Website, Web Messaging,

Telephone and Selective Use of Office Telephone and Selective Use of Office VisitsVisits

Physician Spends Half Day Seeing Physician Spends Half Day Seeing Patients – Visits 30 Minutes or LongerPatients – Visits 30 Minutes or Longer

Half Day MessagingHalf Day Messaging Volume is 20% Visits, 40% Telephone, Volume is 20% Visits, 40% Telephone,

40% Web Messaging40% Web Messaging Annual fees range from $195 to $495 Annual fees range from $195 to $495

depending on agedepending on age

Kaiser Kaiser Permanente Permanente

HealthConnectHealthConnect24 Hour Access to 24 Hour Access to

Accurate and Accurate and Comprehensive Health Comprehensive Health Care Information and Care Information and

ServicesServices

Dr. Christy Calderon, a Dr. Christy Calderon, a family physician at Kaiser family physician at Kaiser

Permanente’s Whittier Permanente’s Whittier office, conducts as many office, conducts as many as half her appointments as half her appointments over the phone or online over the phone or online

with a 3 inch camera with a 3 inch camera affixed to her desktop.affixed to her desktop.

Los Angeles Times, Feb. 4, Los Angeles Times, Feb. 4, 20082008

Financial Models for the Financial Models for the New ModelNew Model

Shift of telephone to E-mail (time saver, $ Shift of telephone to E-mail (time saver, $ neutral)neutral)

Reduce unnecessary visits (more $ in high Reduce unnecessary visits (more $ in high demand office, less $ in lower demand)demand office, less $ in lower demand)

Payment for virtual care (Web Visit Payment for virtual care (Web Visit Charges)Charges)

Prepaid service fee, monthly ($30) or Prepaid service fee, monthly ($30) or annual ($360)annual ($360)

Prepaid Contracts Prepaid Contracts Pay for Performance incentivesPay for Performance incentives Billing for Group VisitsBilling for Group Visits

Finances Follow Finances Follow Innovation Innovation

The New Model is More The New Model is More EfficientEfficient

Better Faster Cheaper!Better Faster Cheaper!

The Secret Sauce for The Secret Sauce for SuccessSuccess

Care becomes Care becomes continuouscontinuous access rather than episodicaccess rather than episodic

Care becomes Care becomes proactiveproactive rather than reactiverather than reactive

Patients become activated for Patients become activated for self-managementself-management

Relationship Relationship Centered CareCentered Care

What is the 21What is the 21stst Century Century

Application?Application?

Substance is enduring, form is ephemeral. Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two Failure to distinguish clearly between the two is ruinous. is ruinous.

Success follows those adept at preserving Success follows those adept at preserving the substance of the past by clothing it in the substance of the past by clothing it in the forms of the future. the forms of the future.

Preserve substance; modify form; Preserve substance; modify form; know the difference.know the difference.

Wise Words from Dee Wise Words from Dee HockHock

Change Is Disturbing Change Is Disturbing When It Is Done To When It Is Done To

Us. Change Is Us. Change Is Exhilarating When It Exhilarating When It

Is Done By UsIs Done By UsRosabeth KantorRosabeth KantorHarvard Business Harvard Business

SchoolSchool

Human Nature Changes Human Nature Changes LittleLittle

Caring Remains PrimaryCaring Remains Primary

What Changes Are The What Changes Are The Tools And Methods We UseTools And Methods We Use