In its 2001 seminal report “Crossing the Quality Chasm:  A New Health System for the 21rst Century”, the Institute of Medicine (IOM) described the current state of health care delivery.  The report described a health care system that was fragmented, poorly designed and most importantly not delivering quality care. It also outlined a plan with very specific performance objectives designed to close the quality gap and support the patient-provider relationship. These objectives called for a radical redesign of the health system to achieve six aims—safe, effective, patient-centered, timely, efficient, and equitable care.  A new phase in health care improvement is now emerging: one that focuses on value. Value considers providing safe, effective, and efficient care at the right cost. The Institute for Healthcare Improvement (IHI) has developed a model for optimizing health, care experience, and costs for populations -- The Triple Aim. This is a structure in which we know and care about:

1. Patient and Family experience,
   
2. The quality of care delivered, and
   
3. How our efforts impact the cost of care.
   

I would add from my own perspective that we care about our community and providing care for all.

My career started working as a nurse in a hospital system before I moved to the ambulatory care setting. As a nurse there are moments in my career that haunt me. These tragic events had catastrophic impact on patients and families. It was not the failure of caring and competent staff which led to these haunting memories--it was the lack of systems and process to support evidence based care. These experiences drive my passion for a healthier health care delivery system.

In my current position with Colorado Beacon Consortium as Director, Community Collaboratives and Practice Transformation, I have the pleasure of helping primary care practices in transformation and learning from their amazing efforts. In my 15 years working with primary care practices, I have never met a staff member clinical or non-clinical who came to work hoping not to deliver the best possible care. Practices need support for these transformational changes.  Having a “small test of change” fail has meaning for clinical staff because of our educational experience. Failure in the clinical training means that a patient is harmed. Clinical staff need to understand that failures in the quality improvement process mean that the team will not be wasting their time on processes that do not bring value to their patients or to the practice.

In an era of incentive programs such as Meaningful Use and system designs such as Accountable Care Organizations, now more than ever strong Primary Care delivery systems is necessary for creating a healthier health care system. Primary Care transformation is integral is achieving the goals articulated in Crossing the Quality Chasm.

Now more than ever Primary Care needs support to transform systems and processes to make their best better. Redesign efforts started with the development of the Chronic Care Model by Dr. Edward Wagner and the MacColl Institute. The Chronic Care Model serves as a structure to organize care delivery for patients with chronic disease by maximizing proactive team based care, implementing processes which deliver evidence based care, utilizing health information technology (HIT) and delivering proactive care. Through several national organizations such as Health Resources and Services Administration (HRSA) Health Disparities Collaboratives, the Institute for Healthcare Improvement (IHI), the MacColl Institute and more recent initiatives such as National Demonstration Project and Improving Performance in Practice (IPIP) best practices in primary care transformation have been developed.

The Patient-Centered Medical Home (PCMH) has been recognized as a catalyst to support Primary Care transformation that delivers on the expectations described in Crossing the Quality Chasm. Agency for Healthcare Research and Quality (AHRQ) describes PCMH as:

• Patient-Centered
  
• Comprehensive  & Coordinated care
  
• Superb access to care
  
• A systems-based approach to quality and safety
  

These attributes must be supported by a foundation of Health Information Technology and rich data which provides knowledge to drive outcomes.  The other structural change must come in the form of a payment structure that supports primary care and the attributes that will drive the value primary care delivery will bring to healthcare.

A comprehensive program to recognize practices who implement the attributes of PCMH has been developed by the National Committee for Quality Assurance (NCQA) Physician Practice Connections- Patient-Centered Medical Home (PPC-PCMH). NCQA has recently updated the recognition program.

The 2011 program includes the core components of primary care:

• PCMH 1: Enhance Access and Continuity
  
• PCMH 2: Identify and Manage Patient Populations
  
• PCMH 3: Plan and Manage Care
  
• PCMH 4: Provide Self-Care and Community Support
  
• PCMH 5: Track and Coordinate Care
  
• PCMH 6: Measure and Improve Performance
  

The transformation process for primary care is more than tinkering around the edges. This process of change requires a foundation of culture and leadership that is supportive of the efforts within the practice. This can be either through the leadership structure of a broader organization or within a small independent primary care practice. The Primary Care Practice team members are being asked to reconsider the hierarchical nature of medicine for a team based approach to patient-centered care. All members of the team to participate in the redesign process and in evidence based care delivery. Practices establish structures to make “small tests of change” that are reviewed to understand if the impact is positive in delivering safe, effective, evidence based care.  Implementing self-management support with primary care builds on the most intimate of relationships between patient & families and the care team. Self-management techniques utilized in the care setting build on patient activation and engagement in their care. Technology is a tool to be maximized and utilized meaningfully.

Clearly, we understand the role of Primary Care in supporting our current sick health care system to become healthier. This transformation takes time and requires support. As we establish principles, goals, care models and incentive programs to create a healthy health care system, it is important not to lose sight of the need to also transform the current payment model with is perfectly designed to assure that our fragmented, ineffective, dysfunctional and harmful health care system continues.

Crossing the Quality Chasm

http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

Institute for Healthcare Improvement

http://www.ihi.org/IHI/Programs/StrategicInitiatives/IHITripleAim.htm

Improving Chronic Illness Care

http://www.improvingchroniccare.org/

HRSA Healthcare Communities

http://www.healthcarecommunities.org/

Agency for Healthcare Research and Quality

http://www.pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/what_is_pcmh_

National Committee for Quality Assurance

http://www.ncqa.org/tabid/631/default.aspx

Office of the National Coordinator for HIT (ONC)

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204

Colorado Beacon Consortium

http://www.coloradobeaconconsortium.org/

Center for Medicare and Medicaid (CMS)

https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp

Partnership with Patients

http://www.healthcare.gov/center/programs/partnership/index.html

The promise of telemedicine has been around for years, with robotic surgeries, remote monitoring of patients and big city doctors able to care for rural patients over computer networks. But not until Apple IOS devices like iPhone and iPad as well as Android OS phones and tablets have been introduced, have we seen the true promise and convenience of what telemedicine can really be. Not on an emergency, expensive basis, but in a day-to-day, real-world kind of way.

Widespread use of remote monitoring over broadband networks, located in both institutions and homes, to track vital signs and metrics of patients with chronic diseases such as congestive heart failure and diabetes is a critical and urgent development. Remote monitoring can spot health problems sooner, reduce hospitalization, improve life quality and save money. Adoption of remote monitoring technologies will be slowed and benefits reduced unless the United States does a better job of reimbursing health care organizations for remote care and encouraging continued investment in broadband infrastructure that can be tailored to meet privacy, security and reliability requirements for telemedicine applications.

Telemedicine can help those with chronic illnesses to lead normal work and personal lives and enable older Americans to remain in their own homes instead of moving to institutional settings. Remote monitoring technologies can transmit data on a regular, real time basis and prevent hospitalizations by identifying and treating problems by triggering adjustments in care before negative trends reach crisis stage. As a result, increase access to care is achived and hospitalizations can be averted.

However, success in translating potential savings into real savings depends in part on public policy decisions that speed the acceptance and penetration of remote monitoring. The realignment of reimbursement policy for telemedicine is among the most critical policy decisions that need to be made. Right now, like other preventive care, telemedicine is only covered to a limited extent and reimbursement is low. For example, remote consultations with physicians are reimbursed if they are conducted over two-way video. However, physicians are not reimbursed for examining remote monitoring data as a preventive measure. Right now, patients and insurers are capturing many of the quality improvements and cost savings from telemedicine, but paying for few of them. The costs are largely incurred by health care providers, but not fully reimbursed. This leaves little incentive to encourage optimal levels of investment and commitment to the provision of telemedicine infrastructure and services.

As someone interested in innovation in health care, I’m very much excited about technologies like Apple’s Facetime, a video calling protocol that can be used by iPhone 4 users. I see FaceTime as a catalyst for renewed interest in telehealth. This type of technology lowers the cultural barrier to telemedicine as well as increasing its use by the general public.

What makes FaceTime different from existing telemedicine applications? The first thing is that it is simple to use. All you need is a phone number/email address and an Internet connection. Dedicated hardware or need to go to a specialized room is bypassed. Privacy can be secured in a variety of locations instead one sanctioned spot in a facility.

Recently, I was privy to an FDA-cleared platform which allows patient information - including waveforms and other critical data from EMRs, bedside monitors and devices, pharmacy, lab, and other clinical information systems - to be securely and natively accessed by physicians and nurses on their smart phones or tablets…anytime, and anywhere. Airstrip Technologies has launched an exciting set of enterprise-wide solution that delivers waveforms (cardiac, SPO2, ventilator, arterial line, etc.), vital signs, medications, I&Os, lab results, allergy lists, and EMR data for patients in areas such as ICUs, CCUs, PACUs, Ors and EDs. Users can refer to current or historical results through the patient medical file by simply selecting the required results view.

Quite simply, we need integrated technology policies. We need policy incentives that ensure institutions and practitioners who invest in telemedicine are sufficiently compensated for the resulting improvements in both care and costs. Policies that bring broadband technologies into more homes will also help bring in remote monitoring, video visits with providers, and self-care education. Policies and advances in products that increase the public’s fluency with advanced communications technology will make telemedicine more effective and easier to implement. In addition to policies we needs investments in networks to increase capacity for live video and continuous monitoring. Smart communications policy also can expedite the adoption of remote monitoring and other telemedicine technologies.