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Advances in medicine and technology have vastly expanded the capacity of our health care system to prevent, diagnose, treat, and cure illness. But often, even as doctors, nurses, and other health professionals strive to deliver the best care they can, standard medical practice has not kept pace with these advances, resulting in a growing gap between what medical care could offer and what it does offer.
The rapid advance in medical knowledge has made it difficult, for example, for individual physicians to know everything that might benefit their patients, or what treatment strategies are most effective and efficient. According to Dr. Thomas Lee, head of the physician network associated with Partners HealthCare in Boston, “When I graduated from medical school, everything I needed to know was in books I could read. Today, it’s impossible to read and know all that is available. A computer with prompts and recommendations is essential to the practice of modern medicine.”
That’s the philosophy behind Partners HealthCare’s High Performance Medicine initiative, launched four years ago by Partners President and CEO Dr. James Mongan. Partners is an integrated health system affiliated with Harvard Medical School that includes Brigham and Women’s Hospital and Massachusetts General Hospital as well as community and specialty hospitals, a physician network, community health centers, and home health and long-term care services.
“At Partners, we are convinced that the issue of value, which encompasses quality, safety, and efficiency, will be critical to our success over the coming decade,” says Dr. Mongan. “High Performance Medicine means going beyond the clinical excellence of our individual physicians, nurses, and other caregivers. It means accepting our responsibility not just to assert our quality, but to demonstrate it; setting the goal of continuous quality improvement; taking responsibility for both improved quality and efficiency; and keeping the focus on each individual patient while also monitoring the care of key populations of patients over time.”
Through its High Performance Medicine initiative, Partners is seeking to improve in five key areas:
- Maximizing the use of new information technology
- Increasing patient safety and reducing medical errors
- Making high quality uniform across the Partners system
- Better coordinating care for the sickest and most expensive patients
- Improving efficiency in the use of high-cost drugs and radiology tests
Over the past four years, Partners has made significant progress in each of these areas.
SHUFFLING LESS PAPER
In 2005, computerized ordering systems that guide physicians to the most cost-effective drugs and tests were being used in about 8 percent of U.S. hospitals with fewer than 300 beds and 17 percent of hospitals with 300 or more beds. These rates are expected to rise, but very slowly, to only 37 percent and 53 percent, respectively, by the year 2010.
Partners has already far exceeded these end-of-decade national projections, with computerized ordering of drugs and tests now fully implemented in all of its acute care hospitals.
Similar progress has been made in the implementation of electronic medical records, which allow physicians throughout the Partners system to access a patient’s medical record and better coordinate patient care. Currently, more than 70 percent of Partners physicians use electronic medical records. Among primary care physicians, EMR use has grown from less than 10 percent in 2003 to more than 85 percent today.
Partners has set strict deadlines for the adoption of EMR, with all PCPs required to implement or sign a contract for EMR by the end of 2007 and all specialists for whom EMR is appropriate required to implement or sign a contract for EMR by the end of 2008.
REDUCING MEDICATION ERRORS
By 2010, all Partners hospitals will have in place integrated systems to minimize medication errors. These systems begin with computerized order entry. Next come measures like “smart pumps” for intravenous drugs and “bar coding” of medications and patient identification bracelets to ensure that the right patient gets the right drug at the right dose at the right time.
Research at Partners hospitals and elsewhere has shown that such systems dramatically reduce medication errors. Use of computerized provider order entry alone reduced medication-related errors by 55 percent in one trial. Another study found that improvements in “decision support” that automatically evaluates a drug’s risk to an individual patient led to an 83 percent reduction in the overall rate of medication errors.
IMPROVING CARE FOR KEY POPULATIONS
Partners has developed software that identifies and tracks key patient populations, such as
patients with acute myocardial infarction, heart failure, and diabetes, to ensure they have received all recommended interventions. Whether these quality standards are met is systematically measured on an ongoing basis, and linked to focused efforts to improve care against these standards. These efforts, in turn, are enhanced by Partners ability to build clinical pathways into its electronic records which help ensure that essential treatments, such as aspirin and beta blockers for heart attack patients, are delivered.
Partners hospitals and clinicians have an excellent performance record in the reliability of care provided to patients who have suffered a heart attack or who have diabetes or heart failure. For example, among the system’s 12,000 diabetes patients, the rate of Hemoglobin A1c screening puts Partners in the top 10 percent of hospitals nationwide. In virtually all areas of diabetes and other quality measures, Partners hospitals are among the market leaders in Massachusetts and nationally.
FOCUSING ON THE SICKEST PATIENTS
It is hard to ignore the fact that 10 percent of patients account for 70 percent of health care costs and that only one percent of patients account for 30 percent of costs. In this context, Partners has focused on improving the effectiveness and efficiency of providing care to these very sick patients in three ways: using “smart” software to identify in advance the small number of patients who are likely to become the most expensive; instituting and expanding a congestive heart failure management pilot program that has demonstrated a 15-20 percent reduction in hospital readmissions; and, launching with the blessing of state officials a 24/7 nurse coaching program for 6,000 high-risk Medicaid and uninsured patients.
DRUG AND RADIOLOGY COSTS
To address two areas of high cost, Partners has developed decision support systems for physicians in prescription writing and in the use of expensive radiology tests. Committees of physician experts, supported by pharmacists and other staff, have developed guidelines for which medications and which tests should be used first, ranging from “green” (most favored), to “yellow” (second choice), to “red” (last choice). This system has allowed Partners to improve its efficiency in the use of drugs and tests and allowed the organization to collect the vast majority of withhold tied to efficiency in its pay-for-performance contracts.
Today, more than two-thirds of prescriptions being ordered by Partners physicians are for generics, up from about 50 percent five years ago. Partners has also established a new Center for Drug Policy to study the effectiveness of new drugs before or as they are being introduced to the market.
Finally, Partners has launched a major new initiative on variation as part of its efforts to enhance quality and better manage costs. The Partners team focusing on utilization is exploring peer review as well as initiating pilot projects and developing education programs to evaluate and address practice variation within the Partners system – with the goal of developing the tools necessary to deliver consistently high-quality clinical care while better managing costs.
© Copyright 2007 Partners HealthCare System, Inc.
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