1. The Virtual Connection: Electronic Visits Joseph E. Scherger, MD, MPH National Medical Home Summit March 3, 2009

2. The Holy Grail of Health Care 2009 Cost Reduction Cost Reduction Quality Improvement Quality Improvement Service Improvement Service Improvement

3. The Secret Sauce for Success Care becomes continuous access rather than episodic Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Care becomes proactive rather than reactive Patients become activated for self- management Patients become activated for self- management

4. NCQA Recognition as a PCMH Access and Communication Access and Communication Patient Tracking and Registry Functions Patient Tracking and Registry Functions Care Management Care Management Patient Self-Management Support Patient Self-Management Support Electronic Prescribing Electronic Prescribing Test and Referral Tracking Test and Referral Tracking Performance Reporting and Improvement Performance Reporting and Improvement Advanced Electronic Communications Advanced Electronic Communications

5. 58 y/o female with obesity and diabetes comes in with symptoms of fatigue, insomnia and back pain. She has a 15 minute appointment HEDIS diabetes measures for this patient: Percent with an annual retinal exam Percent with an annual retinal exam Percent with one of more glycohemoglobin tests Percent with one of more glycohemoglobin tests Percent of those having glycohemoglobin tests showing a level of <8.5 percent (goal <7.0) Percent of those having glycohemoglobin tests showing a level of <8.5 percent (goal <7.0) Percent with an annual screening test for microalbuminuria Percent with an annual screening test for microalbuminuria Percent with two or more blood pressure checks per year Percent with two or more blood pressure checks per year Percent of those with one or more blood pressure checks having a systolic BP <135 (goal <<130/80) Percent of those with one or more blood pressure checks having a systolic BP <135 (goal <<130/80) Percent with an annual lipid panel Percent with an annual lipid panel Percent of those with an annual lipid panel showing an LDL level <130 mg/dL (goal << 100) Percent of those with an annual lipid panel showing an LDL level <130 mg/dL (goal << 100)

6. Case con’t Other Diabetes Measures: Flu vax Flu vax Pneumovax Pneumovax Dental visit Dental visit Cardiac screening test? Cardiac screening test? Lab monitoring for side effects of meds Lab monitoring for side effects of meds Annual foot exam Annual foot exam Baseline EKG? Baseline EKG?

7. Case con’t Cancer Screening needs: Colon- needs colonoscopy (or 3 other types of screening) Colon- needs colonoscopy (or 3 other types of screening) Cervical- needs pap if last <1-3 years prior Cervical- needs pap if last <1-3 years prior Breast- needs annual mammogram Breast- needs annual mammogram Osteoporosis screening and prevention Depression Screening and Management

8. Case con’t General health issues: General health issues: Adult Td Adult Td Weight management Weight management Advance Directives/DPOA Advance Directives/DPOA Culturally-sensitive care Culturally-sensitive care Patient Education Patient Education Self Management Self Management Tobacco Screen Tobacco Screen Alcohol screen Alcohol screen Domestic violence screen Domestic violence screen

9. The Time Problem Time Needed for Chronic Illness Care Time Needed for Chronic Illness Care Time Needed for Preventive Care Time Needed for Preventive Care Time Needed for Acute Care Time Needed for Acute Care Total face to face time for 2500 patients Total face to face time for 2500 patients Ann Fam Med 2005;3:209 Am J Pub Health 2003;93:635 10.6 hours a day for 2500 patients 7.4 hours a day 4.6 hours a day 22.6 hours/day

10. The Ticking Clock in the Doctor’s Office: Patients on routine visits to their primary doctors often have lots of questions but not enough time to get good answers NY Times Feb. 6, 2007

11. Information Technology Changing Medicine Patient Information EHR, All Clinical Data Communication Digital Connection of Patients with Caregivers Knowledge Management and Decision Support Tools

12. The First Rule of Redesign Crossing the Quality Chasm Care is Based on Continuous Healing Relationships New Model of Medical Practice Patient Centered Medical Home

13. Health Care Becomes Continuous Patients Live Their Health and Illnesses Every Day Patients Live Their Health and Illnesses Every Day Quality Health Care Offers Continuous Access and Engagement Quality Health Care Offers Continuous Access and Engagement Patients Will Drive the Innovation Patients Will Drive the Innovation Patients Will Have Their Medical Records Patients Will Have Their Medical Records Patients Have Access to All Medical Information – The Return of the Public Library Patients Have Access to All Medical Information – The Return of the Public Library Patients Will Communicate Far and Wide for Care Patients Will Communicate Far and Wide for Care

14. Young Can’t Imagine Life Without Online Access Associated Press December 5, 2004

15. Why Use E-Visits? Improve patient access Improve patient access Enhance patient education Enhance patient education Increase patient satisfaction Increase patient satisfaction Reduce telephone time and costs Reduce telephone time and costs Can balance risks and benefits Can balance risks and benefits Competitive advantage Competitive advantage Transform work schedule Transform work schedule

16. Benefits of E-Mail Visit extender - increased communication Visit extender - increased communication Patients forget questions Patients forget questions Intimidated face-to-face Intimidated face-to-face Enhance participatory relationship Enhance participatory relationship Change service utilization Change service utilization Behavioral coaching Behavioral coaching

17. Potential Problems with E-Mail Confidentiality and security Confidentiality and security Time demands Time demands Misinterpretation Misinterpretation Inappropriate uses Inappropriate uses Digital divide Digital divide

18. Myths About Patient E-Mail Myth #1: Hackers could read my patient’s confidential messages. Myth #1: Hackers could read my patient’s confidential messages. Myth #2: It will take more time from my day, and I won’t get reimbursed for it. Myth #2: It will take more time from my day, and I won’t get reimbursed for it. Myth #3: If I allow patients to e-mail me, I will receive a flood of e-mail messages. Myth #3: If I allow patients to e-mail me, I will receive a flood of e-mail messages. Myth #4: Patients will ramble. Myth #4: Patients will ramble. Myth #5: I may get sued, and a lawyer will discover my e-mail messages. Myth #5: I may get sued, and a lawyer will discover my e-mail messages.

19. The New Communication Interactive Web Site For: Lab Results And Other Data Lab Results And Other Data Arranging Preventive Services Arranging Preventive Services Chronic Illness Care Chronic Illness Care Behavioral Coaching Behavioral Coaching Group Visits Group Visits Minor Acute Problems Minor Acute Problems

20. LDL Management May Be Easier With E-Mail Family Practice News, July 1, 2004 Family Practice News, July 1, 2004 William T. Lester William T. Lester Randomized Trial at Mass Gen Hosp Randomized Trial at Mass Gen Hosp Better Management Better Management Fewer Visits Fewer Visits

21. The Doctor Is Online Simply providing a surgeon’s e-mail address nearly triples the likelihood that a patient will contact the doctor about the surgery New York Times, Feb. 18, 2008

22. RelayHealth study California study with Blue Cross of California California study with Blue Cross of California Controlled trial with 5727 patients Controlled trial with 5727 patients Physicians reimbursed $25 per visits with patients having a $0-10 co pay Physicians reimbursed $25 per visits with patients having a $0-10 co pay Results: Results: Overall decrease in spending of $1.92 per patient per month for office visits, $3.69 overall Overall decrease in spending of $1.92 per patient per month for office visits, $3.69 overall Improved patient satisfaction Improved patient satisfaction

24. 1000 pts @ 5 min/email ≈ 8 hrs/week/1000 pts 1000 pts @ 10 min/email ≈ 16 hrs/week/1000 pts Time spent on patient email is predictable…

25. Old Schedule First patient at 8 am and 12 patients each half day session First patient at 8 am and 12 patients each half day session 24 patient visits 24 patient visits 12 patient phone calls 12 patient phone calls Done at 6:30 PM Done at 6:30 PM Patients served -- 36 Patients served -- 36

26. New Schedule Begin e-mail at 8 am and communicate with 15-20 patients. Begin e-mail at 8 am and communicate with 15-20 patients. First patient at 9:30. 6 patients/session First patient at 9:30. 6 patients/session 12 Patient Visits – vary in length from brief to extended 12 Patient Visits – vary in length from brief to extended 4 patient phone calls 4 patient phone calls 34 patient e-mails in 2 sessions lasting 30-45 min. each 34 patient e-mails in 2 sessions lasting 30-45 min. each Done at 5:30 PM Done at 5:30 PM Patients served -- 50 Patients served -- 50

27. A New Model of Office Practice 50% More Caring Interactions Each Day 50% More Caring Interactions Each Day 10-12 Unhurried Office Visits Each Day 10-12 Unhurried Office Visits Each Day Advanced Access – Do Today’s Work Today Advanced Access – Do Today’s Work Today Patients Get All the Time They Need Patients Get All the Time They Need Patients Receive the Excellent Care Patients Receive the Excellent Care

28. How? An Interactive Practice Website An Interactive Practice Website 40-60% of Patient Needs Handled Online or by Telephone 40-60% of Patient Needs Handled Online or by Telephone Electronic Health Records with Imbedded Knowledge Management Tools Electronic Health Records with Imbedded Knowledge Management Tools Great service Great service

29. Concierge Care for Everyone? Fewer Patients per Family Physician Fewer Patients per Family Physician Continuous Availability Continuous Availability Focus on Comprehensive Care Including Prevention Focus on Comprehensive Care Including Prevention Enhanced Professional and Patient Satisfaction Enhanced Professional and Patient Satisfaction Is Concierge Practice the Custom Invention that will lead to the Model of the Future? Is Concierge Practice the Custom Invention that will lead to the Model of the Future? American Society of Concierge Physicians is now the Society for Innovative Medical Practice Design American Society of Concierge Physicians is now the Society for Innovative Medical Practice Design Make it Affordable Make it Affordable

30. Greenfield Health 9 FPs and IMs Practice in Portland, OR, 2 offices 9 FPs and IMs Practice in Portland, OR, 2 offices Chuck Kilo as Leader (IHI Experience) Chuck Kilo as Leader (IHI Experience) Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Interactive Website, Web Messaging, Telephone and Selective Use of Office Visits Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Physician Spends Half Day Seeing Patients – Visits 30 Minutes or Longer Half Day Messaging Half Day Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Volume is 20% Visits, 40% Telephone, 40% Web Messaging Annual fees range from $195 to $495 depending on age Annual fees range from $195 to $495 depending on age

31. Kaiser Permanente HealthConnect 24 Hour Access to Accurate and Comprehensive Health Care Information and Services

32. Dr. Christy Calderon, a family physician at Kaiser Permanente’s Whittier office, conducts as many as half her appointments over the phone or online with a 3 inch camera affixed to her desktop. Los Angeles Times, Feb. 4, 2008

33. Financial Models for the New Model Shift of telephone to E-mail (time saver, $ neutral) Shift of telephone to E-mail (time saver, $ neutral) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Reduce unnecessary visits (more $ in high demand office, less $ in lower demand) Payment for virtual care (Web Visit Charges) Payment for virtual care (Web Visit Charges) Prepaid service fee, monthly ($30) or annual ($360) Prepaid service fee, monthly ($30) or annual ($360) Prepaid Contracts Prepaid Contracts Pay for Performance incentives Pay for Performance incentives Billing for Group Visits Billing for Group Visits

34. Finances Follow Innovation The New Model is More Efficient Better Faster Cheaper!

35. The Secret Sauce for Success Care becomes continuous access rather than episodic Care becomes continuous access rather than episodic Care becomes proactive rather than reactive Care becomes proactive rather than reactive Patients become activated for self- management Patients become activated for self- management

36. Relationship Centered Care What is the 21 st Century Application?

37. Substance is enduring, form is ephemeral. Failure to distinguish clearly between the two is ruinous. Success follows those adept at preserving the substance of the past by clothing it in the forms of the future. Preserve substance; modify form; know the difference. Wise Words from Dee Hock

38. Change Is Disturbing When It Is Done To Us. Change Is Exhilarating When It Is Done By Us Rosabeth Kantor Harvard Business School

39. Human Nature Changes Little Caring Remains Primary What Changes Are The Tools And Methods We Use