Pilot/demonstration projects using collaborations between academic health centers and community-based organizations or community-based research networks that bring CER into community settings. To embed comparative effectiveness research (CER) into community practice, we must consider the current US healthcare system which is in crisis, particularly primary care. Even for those with insurance, the system is fragmented, increasingly costly, difficult to access and navigate, duplicates services, does not connect patients, primary care physicians, and specialists, nor assures treatment and prevention guidelines are followed for a given patient. People expect their primary care physician to be their point of access to healthcare and to assure that the care they receive within the system is evidence-based, cost-effective, coordinated, and safe. Unfortunately, primary care providers do not have the systems in place and are not paid to coordinate care. This results in emergency rooms, the most costly sites for care, being a major site for primary care problems for both uninsured and insured patients and a portal of access for indigent specialty care. There has not been a business model to support the necessary services and technology-supported processes to assure a patient has an accountable healthcare delivery system. To address these issues, we propose to pilot a Medical Home intervention in a community-based setting. The Medical Home model is seen as a key component for reforming care by all major clinical and payer organizations, although to date, there has been little rigorous evaluation of the medical home model. The Medical Home model is based on an electronic data infrastructure that we have built that allows physicians to coordinate care, evaluate the quality of the care provided, and participate in quality improvement initiatives. In addition, this data infrastructure provides the opportunity for community based comparative effectiveness research to be carried out and to have an impact. The Medical Home intervention we propose, the Your Doctor Program Medical Home System (YDP-MHS), overcomes three key barriers to the implementation of an integrated continuity of care model providing high quality care. The first is a health information system infrastructure for collecting information across the silos of care (primary care physician, specialist, hospital, laboratory, pharmacy, et cet.). The National Commission on Quality Assurance (NCQA) has standards for the Medical Home but does not provide a health information system infrastructure that supports its rapid, large scale implementation. We have developed an approach for a Health Information Exchange that collects information across the silos of care as part of the YDP-MHS. This data bases infrastructure also forms the basis for community based comparative effectiveness research. The second is the barriers to physician collecting quality of care data and adopting guidelines for quality improvement. Physicians often feel quality outcomes comparisons are inaccurate because they rely on billing data and do not adequately adjust for risk. The YDP-MHS supports the implementation of the NCQA standards in a physician's practice and engages physicians in collecting quality of care data and in outcomes improvement initiatives. The third barrier is payment models for physicians to coordinate care and collect quality of care data. Private and public insurance payers have agreed to pay private and safety net physicians'incentives for participation in the YDP-MHS. This demonstration pilot offers the opportunity for embedding a comparative effectiveness research infrastructure into a community setting. Technical proof of concept in up to fifty primary care practices Aim 1: Assess Your Doctor Program Medical Home System (YDP-MHS) impact on avoidable emergency center visits for primary care problems for safety net and private patients.
Aim 2 : Assess the YDP-MHS impact on the patient's experience of the health care system using the Consumer Assessment of Physicians and Healthcare Survey.
Aim 3 : Develop and field test with physicians the metrics to compare the effectiveness of physician treatment patterns on clinical indicators while incorporating measures for patient adherence and risk adjustment factors. Cost-effectiveness analysis of YDP-MHS Aim 1: Develop and test a cost-effectiveness model of the YDP-MHS intervention by comparing the costs of care and outcomes before and after the intervention. Diffusion of YDP-MHS Aim 1: Based on lessons learned with the YDP-MHS community model, develop an expansion plan.
Our aims are to evaluate a rapid implementation of a medical home model on costs, patient acceptance, doctor acceptance, and impact on quality of care indicators. The model is supported by an open source technology stack that is highly scalable. The short implementation timeframe for physician adoption and the financial incentives for data management to assure quality are of a sufficient nature to gain widespread acceptance by primary care physicians. We believe that the approach with the medical home / health information exchange strategy will accomplish four things that will impact public health: First, we plan to overcome resistance in building health information exchanges / community clinical data warehouses to share data among competing groups. However, because of HIPAA, patients have a right to have access to their health information. Given that within our model, they have designated their medical home physician as the co-manager of their personal record, the YDP-MHS organization """"""""deposits"""""""" the data into the patient's Quality Health Record that combines the Personal Health Record and the Health Information Exchange, thus increasing the completeness of patient data available for analysis. Second, outcomes data and encounter data is not routinely collected or analyzed on all patient encounters with the healthcare system. We will be gaining experience on how to define processes to assure its collection on all major encounters, including the ability to risk adjust it for analysis. Third, we believe the financial models that will emerge with these payers will be important for defining broader payer adoption for expanding the medical home model. Fourth, we will have a data set to compare safety net and private patients, treatments, and effectiveness to be used for comparative effectiveness research in community settings
