Pioneering Ideas

Making Decisions about Nurse Practitioners’ Scope of Practice

Dr. David Eddy, founder of Archimedes, recently visited the Foundation to present ARCHeS, a Web-based delivery platform that enables policy-makers and health leaders to use the Archimedes model to run their own virtual trials. Dr. Eddy demonstrated a prototype version of what users can expect to access via ARCHeS and previewed new functionality that will allow providers and decision makers to use the model to tailor care decisions for individual patients. Pioneer is supporting Archimedes to build ARCHeS.  

What struck me about ARCHeS was the opportunity it presented to make evidence-based policy decisions about nurse practitioners’ scope of practice that could potentially result in significant savings. Currently, those who advocate for nurse practitioners playing an expanded, autonomous role in delivering primary care point to seminal evidence showing comparable outcomes in patients randomly assigned to either nurse practitioners or physicians where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians. Though this research is not without its critics, it has been used successfully to convince many to see nurse practitioners as part of the solution to expanding access to primary care.  

Nevertheless, the debate around whether and how nurse practitioners’ scope of practice should be expanded and standardized nationally requires evidence that digs deeper into aggregate results. Policy makers need access to evidence that elucidates what nurse practitioners can do as well as physicians vs. tasks/responsibilities that should be left to physicians.  

For example, in his presentation, Eddy showed how ARCHeS, using evidence about both the cost and outcomes of nurse practitioners, indicates that having nurse practitioners administer shots to reduce cholesterol has a striking impact on the cost per QALY for a treatment option. Funders, including NIH, could use these criteria to prioritize funding condition/procedure-specific randomized control trials (RCTs) and other studies.  

To learn more about the implication of ARCHeS, I recommend reading a special report from Business Week entitled “Trimming Health-Care Costs Without Reforming the System,” which implies that the Archimedes model, when made accessible to policy makers and other decision makers, could lead to better decisions that could save billions in health care costs.

Family Coaching Clinics – A Uniquely New Way to Provide Behavioral Health Services

Last week, the UCLA Family Commons, a retail-based model designed to deliver behavioral health prevention and early intervention services to families in an accessible way, opened its doors to provide the community a free week-long preview of its services. Located in Santa Monica, the UCLA Family Commons is a prototype family coaching clinic developed by the UCLA Semel Institute for Neuroscience and Human Behavior and funded by Pioneer.

The concept caught our eye in 2007 when it was chosen as a winner in Ashoka’s Disruptive Innovations in Health and Health Care competition. Modeled after the successful retail health clinic model, we saw it as a promising way to empower consumers. The Family Coaching Clinics model provides families with the support, guidance and structured approach to problem solving that a preventive approach to mental health offers.  Targeted at families with children of all ages, the UCLA Family Commons provides evidence-based products and services to help address problems and stressors that affect so many families – learning to set appropriate limits at different ages, coping with the effects of divorce, developing good eating habits, dealing with bullying in school and so on. The concept is based around the belief that many issues children and families face can be managed if addressed early, and siting the clinics in storefront retail locations reduces the stigma associated with traditional mental or behavioral health counseling, allowing the expert teams at UCLA to reach families who might otherwise never seek out traditional services or might not do so until crises arise.

 

Through December 23, the community can drop in and try out a variety of the clinic’s services. The UCLA Family Commons will then close its doors until its grand opening in early February. If proven successful, project leaders will aim to recreate the Family Commons model in other markets, creating a network of retail-based family coaching clinics. The approach could transform treatment and delivery systems for common childhood problems and, ultimately, change public perceptions of the role of prevention and early intervention in mental health care.

Open Notes and the Electronic Medical Record Podcast

"If you had the chance to look at what your physician wrote in your medical record about your last visit, would you take advantage of it?  Would this make your relationship with your doctor or primary care provider more collaborative? More effective?" These are just a few of the topics that host Madge Kaplan covered in yesterday's dynamic and engaging WIHI podcast on the Open Notes project and electronic medical records.

Guests included Dr. Tom DelBanco of Beth Israel Deaconess Medical Center and the Open Notes Project, as well as, Dr. Mary Merkel, a family practioner at Dartmouth-Hitchcock and Bob Desauiniers, Dr. Merkel's patient.

If you weren't able to catch yesterday's live broadcast, we encourage you to listen to the archived recording. You can also access additional information on the Open Notes project and the resources mentioned during program.

Gearing Up for the 2010 Games for Health Conference

The details have been announced for the sixth Games for Health Conference, the premiere annual event focusing on the role of digital interactive games in health and health care.

On May 25-27, 2010 at the Hyatt Harborside in Boston, health game developers, researchers, advocates and enthusiasts from all over will participate in specially developed learning and networking tracks: Active Gaming, Medical Training & Education, Physical Therapy & Rehab and Cognitive Gaming.  Have an idea for a session? Deadlines are fast approaching for the call for content so make sure to get your submissions in now.  

Every year, the Pioneer team shares highlights here on the blog and on our twitter account. While we will surely be sharing information before, during and after the event, we encourage you to experience the conference firsthand. Click here to register  and we hope to see you there!

Pushing Ahead with Malpractice Reform...

We encourage you to pop over to RWJF’s Health Reform Galaxy Blog to read a post from Philip K. Howard - Founder & Chair, Common Good - on the future of Health Courts and medical liability reform.

An “exaflood” of Observational Data

Today’s New York Times has a book review of THE FOURTH PARADIGM: Data-Intensive Scientific Discovery.  It’s a collection of essays edited by Tony Hey, Stewart Tansley and Kristin Tolle from Microsoft Research.  According to John Markoff’s review, “The essays focus on research on the earth and environment, health and well-being, scientific infrastructure and the way in which computers and networks are transforming scholarly communication. The essays also chronicle a new generation of scientific instruments that are increasingly part sensor, part computer, and which are capable of producing and capturing vast floods of data."

This is an area we've been interested in for awhile...our program, Project Health Design: Rethinking the Power and Potential of Personal Health Records is exploring how people with chronic conditions can improve their health and wellbeing by capturing, understanding, interpreting and acting on information they capture from the patterns of their everyday lives - Observations of Daily Living. It's also looking at how that information can be fed back to clinicians and integrated into their workflow.

What We Are Watching: Extending the Cure on the INQRI Blog

Over the next two weeks the Interdisciplinary Nursing Quality Research Initiative (INQRI) is commemorating the 10-year anniversary of the influential Institute of Medicine (IOM) report "To Err Is Human” with a series of blog posts. 

Today, the series featured a compelling video interview with Ramanan Laxminarayan of Extending the Cure – a Pioneer grantee. Dr. Laxminarayan discusses how hospital-acquired infections (HAIs) have evolved over the last ten years; the role that antibiotic resistance plays in HAIs; and the challenges in changing hospital culture. You can check out the video here.

David Eddy, Opening Doors to the Future

I have heard David Eddy present a half-dozen times, and each time come away with a richer appreciation of the door to the future he is opening for us. He was at the Foundation talking to staff today, and presentation stood out as being special because he started with an historical perspective of how we have defined quality of medical care over time, moving from qualitative judgment to quantitative measurement as the data and tools for modeling have improved.

And while he is somewhat modest, it is clear that David has figured prominently in that history, challenging the system to evolve as new data and methods have been developed. He gave us the concept of evidence-based medicine when we had none. He helped to create the HEDIS measures and gave us evidence-based guidelines of care for population-based health measures. Now he is giving us personalized guidelines which will be aggregated to develop new Global Outcome (GO) Scores for accountable care organizations to manage the health of their members.

It cements in my mind the importance of creating ARCHeS to give many more policymakers access to the power of the Archimedes model that David and his colleagues have developed.  I feel like I have had a glimpse of the future, and we really could have the best health care system in the world.

Patient Safety and Medical Liability Reform Forum

This Thursday, Common Good, with support from Pioneer, will host an event in DC to discuss advancing patient safety and medical liability reform innovations. The forum’s topic is prompted by the September announcement from President Obama that the Department of Health and Human Services will launch a $25 million initiative to help states and health systems conduct innovative patient safety and medical liability demonstration projects. Health Courts could prove to be one of the key projects that states bring forward to the Agency of Healthcare Research and Quality (AHRQ) – administer of the grant – this coming January.

The event’s lineup includes some terrific panelists and is sure to generate interesting dialogue and ideas.

Common Good invites anyone who is interested in this issue to tune into the live webcast– feel free to share the link with other colleagues and contacts.  Here are specifics:

WHAT:  A forum on patient safety and medical liability reform.

WHO:

Dr. Lucien L. Leape, Chair, Lucian Leape Institute at the National Patient Safety Foundation

Michelle Mello, Professor of Law and Public Health, Harvard School of Public Health (and former Pioneer health courts grantee)

Nancy Foster, Vice President for Quality and Patient Safety Policy, American Hospital Association

Dr. Albert Stunk, Deputy Executive VP, the American College of Obstetricians and Gynecologists

Elaine Brightwater, Senior Project Coordinator, Center for Development & Disability, Uni. of New Mexico

Richard Boothman, Chief Risk Officer, University of Michigan Health system

Gordon Smith, Executive Vice President, Maine Medical Association

Dr. Alan Woodward, Former President, Massachusetts Medical Society

Martin Hatlie, President, Partnership for Patient Safety

David Oakley, Counsel, Healthcare, Manatt, Phelps & Phillips, LLP

Philip K. Howard, Chair, Common Good

WHEN:  Thursday, December 10, 8:30 a.m. – 2 p.m.

WHERE:  Via live webcast

Healthy Conversations: Paul Tarini

Andre Blackman's Pulse & Signal has an interview with Pioneer Portfolio Team Director Paul Tarini.

Make sure to check out the original post here.

Talking About Philanthropic Failure

In a new Communications Network diavlog (no, that isn't a misprint, it is an awkward attempt to combine dialog, video, and blog), Pittsburgh Foundation President Grant Oliphant talks about failure. It is good to see more attention to this topic. Paul Brest of the Hewlett Foundation and Jim Canales of the Irvine Foundation have been outspoken about the need to be more forthcoming about programs that don't work, and Robert Giloth and Susan Gewirtz from Annie E. Casey Foundation document the potential value of foundation mistakes in the Winter 2009 issue of Foundation Review. So the issue is beginning to get traction. The Robert Wood Johnson Foundation's recently released Anthology (Volume XIII) adds to the mix with four chapters on foundation failures.

In his remarks, Oliphant comments about good and bad reasons for talking about failure. Good reasons include not wanting to hurt grantees or the cause intended to be helped - i.e., do no harm. Bad reasons include foundation embarrassment.

I’d offer two more – one good reason to talk about failure and one bad reason.  The bad reason is fear – fear of being held accountable for using tax-protected dollars in ways that don’t lead to results.  That fear is understandable, but it undercuts the very role that foundations are in the best position to take: reasonable risks on potentially high-impact activities that are less likely to attract support in the business or public sector.

 

The good reason starts with asking the question: why does the topic of failure even come up in the first place?  After all, the performance of most organizations is the constant subject of many outside observers. But that is the point - foundations are not the subject of systemic observation, in part because they occupy a relatively powerful and independent status in our society. As I argue in the RWJF Anthology, it is this very independence that drives the need for foundations to themselves generate the honest, critical assessment of their performance that is so important to their missions.

 

Finally, do you know of foundations that expect failure? RWJF's attention to failure is tied to different levels of risk intended to be taken by different grant portfolios in the Foundation. As my colleague Paul Tarini, Team Director of the Pioneer Portfolio, noted here, Pioneer expects more failure than other RWJF portfolios because it aims to support highly innovative, high-risk projects. If you are aware of other funding efforts designed to be high risk, and expect more failure, please let us know so we can learn from each other.