Pioneering Ideas

Positioned for Transformation: Expanding the Scope of Health Care

BY DEBORAH H. BAE, SENIOR PROGRAM OFFICE, PIONEER PORTFOLIO AND JANE ISAACS LOWE, TEAM DIRECTOR, VULNERABLE POPULATIONS PORTFOLIO -- @jisaacslowe

In the Stanford Social Innovation Review’s “Realigning Health with Care,” authors Rebecca Onie, Paul Farmer and Heidi Behforouz express their collective belief that—in the United States—we need to expand our understanding of the scope of health care, where it’s delivered and who delivers it. They also make it clear that the time to do so is now if we are going to confront our country’s rising health care costs, primary care physician shortage and expansion of the ranks of those living in poverty or hovering just above it. 

Onie, Farmer and Behforouz also propose that we need to look beyond our shores and borders for models for how to do so, pointing out that “in the developing world, there is no choice but to design health care systems that account for limited financial resources, scarce health care professionals and significant poverty.” 

We couldn’t agree more.

Since 2009, the Robert Wood Johnson Foundation has supported Health Leads, the organization led by Rebecca Onie. Health Leads enables physicians and other health care providers in six U.S. cities to prescribe basic resources, such as food and heat, for their low-income patients—just as they would medication. The model recognizes that, too often, the fact that a family lives in a mold-infested apartment or doesn’t have enough food holds greater influence over whether they can improve their health than medical care or prescriptions. As Onie, Farmer and Behforouz explain, in addition to broadening the scope of health care, Health Leads broadens where it is delivered by using family resource desks in hospital waiting rooms to connect patients with these social resources. And it extends the health care workforce by relying on passionate and skilled college volunteers to work with patients to make those connections.

In addition, the Foundation’s Pioneer team has begun to look overseas for health care solutions that have the potential to be adapted here in the United States. We’re starting off slowly, trying to learn as much as possible from our peers at other foundations who have been funding health care programs overseas for years. For example, we’ve brainstormed with colleagues at the Center for Health Market Innovations, a program funded by the Bill & Melinda Gates Foundation and the Rockefeller Foundation, about scaling and replicating innovative programs and policies that are already improving health care delivery in low- and middle-income countries.  

With this same strategy in mind, we partnered with Ashoka Changemakers to conduct a competition to seek out health care solutions from abroad, announcing the winners last month. In fact, Onie, Farmer and Behforouz highlight one of the winners of the competition in their article: Brazil’s Associação Saúde Criança. Saude Crianca—like Health Leads—recognizes that health care goes beyond the doctor’s office; to be healthy, children under their care need to be able to live in safe homes where they are well-fed and the whole family is supported on a path out of poverty.

We’re also working with the International Partnership for Innovative Healthcare Delivery to explore how health care could be delivered at lower cost by using different models of where health care is delivered and by whom. As Onie, Farmer and Behforouz point out, the United States health care system often relies too heavily on doctors in circumstances where nurses or even community health care workers are skilled to be delivering services more efficiently and at lower cost.

Despite our agreement with Onie, Farmer and Behforouz, we see challenges ahead. To begin with, we need more champions—across all sectors—for programs such as Health Leads, Saude Crianca, or any other model that addresses the gap between a patient’s medical and social needs. To increase awareness and understanding and expand the pool of those willing to advocate for changes in the health care system, the Robert Wood Johnson Foundation, in partnership with Harris Interactive, released the results of a poll late last year highlighting the fact that the vast majority of physicians believe unmet social needs are leading directly to worse health for all Americans. In early April, we hosted an online discussion asking people to share their ideas on bridging the gap between physicians’ desire to address their patients’ social needs and their lack of time or sufficient staff to do so effectively.

In addition to finding champions, we need to continue to eliminate silos that make it difficult for health care providers to address the social factors that are defining their patients’ health outcomes. Hospitals are never going to become social service agencies and they shouldn’t; that's not their expertise. We need to “properly execute the solutions we already have” by building more successful integration between health care providers and those who have the know-how and capacity to respond to patients’ social needs.

As a foundation, we will continue to seek out innovative solutions—overseas and in the United States—and to evaluate the most promising to establish that they are effective and can be spread. Just because it works in Haiti does not mean it will work in Hartford. For those models and approaches we believe can be scaled, we will provide support to enable them to develop strategies for growth that reflect an understanding of which elements of the model or approach are essential for success.

We hope you’ll join us by sharing your ideas, partnering with us to help the most effective ideas achieve the scale they need to transform health on a major scale, and to champion efforts to “make sure that what we call ‘health care’ is broad enough to get the job done.”

As Rebecca Onie, Paul Farmer and Heidi Behforouz make clear, the time to do so is now.

Project ECHO: A Game-Changer for Patient Care?

Note: This post originally appeared on The Health Care Blog June 14, 2011

By BRIAN QUINN, Pioneer Team Director

I met Sanjeev Arora as part of the RWJ crowd at TEDMED last year and was pretty impressed with his approach–especially given the lack of access to care in poor and minority regions. Now there’s proof his approach works –Matthew Holt

On June 1 the New England Journal of Medicinepublished a study about how primary care providers can treat very sick patients who previously did not have access to specialty care.  The piece described Project ECHO, a disruptive model of health care delivery based on collaborative practice that has the potential to transform health care.  Supported by Robert Wood Johnson’s Pioneer Portfolio and based at the University of New Mexico Health Sciences Center (UNMHSC), Project ECHO was developed by Sanjeev Arora, M.D., a hepatologist at UNMHSC and leading social innovator.

The ECHO model organizes community-based primary care clinicians into disease-specific knowledge networks that meet through weekly videoconferencing to present patient cases.  These “virtual grand rounds” are led by specialists at academic medical centers who train providers to provide specialized care, share best practices and co-manage complex chronic illness care for patients with the local care team. Under this model, primary care providers treat patients in their own communities – burdens on academic center capacity are reduced, poor access to care is eliminated  (patients are no longer limited by geography when seeking quality care), and the health care systems’ capacity to provide high quality care to more patients, sooner, is dramatically expanded.

In the NEJM study, patients with hepatitis C treated by primary care clinicians working through Project ECHO achieved results that were identical to patients treated by UNMHSC specialists.  The evaluation also showed that the ECHO model can reduce racial and ethnic disparities in treatment outcomes.

Project ECHO offers promise as a game-changer for how patients with complex illnesses are treated.  Dr. Arora describes the power of ECHO’s knowledge networks as a “force multiplier,” which “transforms the dynamics and the capacity of health care delivery and the spread of best practices.”

In an accompanying editorial, Thomas D. Sequist, M.D., associate professor of medicine and of health care policy at Harvard Medical School and Brigham and Women’s Hospital, said Project ECHO “represents an important step forward” in addressing barriers to accessing specialty care.  He notes that the NEJM study raises several issues, including the need for  adequate health information technology to implement the ECHO model successfully, the critical role of academic medical centers in supporting the model and the potential for meeting local community health care needs by extending the model to additional chronic diseases.

Sequist makes excellent points, and Project ECHO is already addressing them head-on.

The ECHO model harnesses communications technology to form truly collaborative provider partnerships that permit care in home communities.  It connects the wealth of knowledge and expertise housed at academic medical centers and the desire of primary care providers to do more for their patients.  And although the findings from theNEJM evaluation focus on hepatitis C, the Project ECHO model has spread to include asthma, mental illness, chronic pain, diabetes and cardiovascular risk reduction, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology and substance abuse.

ECHO represents a fundamental rethinking of how we use our limited supply of physicians, how we engage a full care team in chronic disease management, how we teach best practices and how we provide access to quality care for all.  We know we have physician shortages, an aging population and 32 million more Americans who are going to become insured in the coming years.  Dr. Arora has developed a disruptive innovation that addresses these challenges.

Through ECHO, providers – not just doctors, but nurses, nurse practitioners, physician assistants and community health workers – are teamed to work together to the benefit of patients who receive accessible, high quality care.

Isn’t that what we all are striving to deliver?

 

It’s Starting to Add Up - A Few Observations from AMIA 2010

I’ve just finished three days at AMIA’s Annual Symposium – the geekfest gathering of informaticians (or informaticists, if you prefer).  It’s a big conference, with many themes and tracks, so it’s hard to draw general conclusions as any observations are largely functions of which sessions one chooses to attend.  So I’ll try not to generalize (too much) but offer a few thoughts on what I saw and heard.

Meaningful Use policy is a really delicate business.  As provider organizations are starting to translate Meaningful Use requirements into operational plans, the details are getting really tricky.  I saw a panel representing some real EHR pioneers (e.g. Intermountain Health Care, Marshfield Clinic) that showed how even for them, who’ve been using EHRs rather meaningfully for years, they will have to make substantial changes to their systems in order to qualify for the subsidies.  Meaningful Use is a great concept because it uses large scale EHR implementation as a vehicle to shift practice in the direction of better quality (good) and more prevention (good again), but doing so without being over-prescriptive is much harder than it looks.  Finding that balance of rewarding the principles while maintaining a fair degree of flexibility on the implementation details seems to be the key (and, to be fair, easier said than done).

Health IT raises interesting questions about roles.  Dan Masys, in his perennially fascinating review of the past year’s research findings and key developments, pointed out that now study after study about clinical decision support shows the same finding:  that decision alerts always have more impact if they are sent to anyone on the care team but the physician.  He also noted that the teachable moment of an order entry system is at the moment of entry (when, for example, a drug-drug interaction or contraindication alert is triggered) and that physicians don’t learn from these opportunities if they delegate the order entry task, as is common.  Dryly, he observed that studies also show that decision support is most effective when it’s not ignored.  On a serious note, he commented that if the trend of these findings continues, disintermediation of physicians will become inevitable.  Ouch.

Rapid Learning is really starting to happen.  I attended a terrific presentation by Nirav Shah, a researcher based at NYU and Geisinger.  He’s been mining Geisinger’s EHR data, which goes back many years now, and doing just the kind of studies one would hope to see when we can start to tap large clinical datasets.  After a preliminary rundown of the pros and cons of mining EHR data vs. running prospective clinical trials, he showed how he was able to compare the effectiveness (not a sanitized clinical trial of efficacy, but actual effectiveness in terms of real-world experience) of a next-generation brand-name drug against a generic (no difference except in cost).  He also showed that he could predict, in 50 percent of cases, which patients would develop congestive heart failure six to 24 months ahead of time.  Wow.  While it would be great to see the 50 percent number climb, that kind of result opens the door for preventive interventions that could save many lives.

Power to the Patients!  One panel brought together some of the true pioneers of patient engagement.  (Okay, I’m a bit biased as RWJF/Pioneer funds two of them currently) Warner Slack, who’s a great-grandmentor of some of the students in the audience (he trained the students that trained the current generation of faculty), gave a hilarious talk about just how strange his colleagues thought him when he was advocating for greater patient participation in clinical decisions 40 years ago.  Tom Delbanco discussed the OpenNotes project , and Patti Brennan discussed Project HealthDesign and the value of tracking observations of daily living (“ODLs,” also a frequent topic on this blog).  Patti gave a very clear explanation of the value of each: OpenNotes, she said, gives a window into what the clinician is thinking; ODLs give the clinician a window into the day-to-day life that a patient is living.  Both, she said, are necessary to improving care.  Charlie Safran made some important observations about the need to drop often stereotypic assumptions about how groups of patients will behave and e-Patient Dave was both passionate and entertaining as he spoke about the value of engaging patients in reviewing their records (not only will they be better informed, they will inevitably fins mistakes – some serious). Dave’s comments raised for me a key point, which is that clinicians should make sure that patients know what’s in their records – not for any moral or philosophical reasons – but for the simple practical reason that it can improve care and safety. 

Those were a few things I noticed.  You can check out the Twitter stream for many perspectives.   I’d love to hear from others who were there and get their take.  And for those who weren’t, are these observations consistent with what you’re seeing?