1. It’s the Systems! L. Gregory Pawlson MD, MPH Executive Vice President NCQA Core Presentation

2. 2 Physician Practice Connection and Patient Centered Medical Home Why Focus on Systems? IOM reports: “ To Err is Human” and “Crossing the Quality Chasm” –both reports provided substantial evidence on critical importance of systems (including evidence from other areas (aviation) Evidence from a few RCT’s (measurement benchmarking and feedback) and studies with reasonable experimental design that systems appear to positively influence quality and efficiency Research showing variance on process outcome measures explained more by site/group than individual clinician Studies of Shortell, Wagner, Roblin and others on importance of structure and organization

3. 3 Physician Practice Connection and Patient Centered Medical Home Focus on systems allows change from “blaming” individual clinicians for mistakes and shortfalls to actions related to improving systems to facilitate clinician success

4. 4 Physician Practice Connection and Patient Centered Medical Home Wagner Model for Effective Prevention and Chronic Illness Care

5. 5 Physician Practice Connection and Patient Centered Medical Home Moving from models to practice Provide additional evidence of linkages between use of systems using structural measures, and both quality and efficiency process-outcome measures Development of reliable and valid tools for evaluating systems presence to use for both research and implementing practice change Create structural measures that are directly actionable and are free from major bias and confounds at physician office practice “microsystems” level – Sample size – Attribution – Need for risk adjustment Link adoption and use of systems to payment

6. 6 Physician Practice Connection and Patient Centered Medical Home Patient Centered Medical Home Delivery System Design Clinical Information Systems Decision Support Self- Management Support What’s Included? (Infrastructure) How Much Used? (Extent) What Functions? (Implementation) Evidence and Scoring (Verification) PPCPPC Wagner Chronic CareModel Community Support Overlap in Content of PPC-PCMH-CCM

7. 7 Physician Practice Connection and Patient Centered Medical Home Office Systems Decision Support Information Technology Delivery System Design Patient Support Implementing and Evaluating PCMH Inputs Evaluation Programs Tools Patient Experience of Care Measures (CG-CAHPS) Clinical Process & Outcome Measures (inc overuse, resource use) (Recognition programs and/or group/plan data) Office Systems Assessment (PPC) Patient Centered Ongoing Care Individual Clinician-Staff Attitudes, behaviors and proficiencies Educational Support Output MOC (Boards) Practice Evaluation Programs

8. 8 Physician Practice Connection and Patient Centered Medical Home Linkage of PCMH to Reimbursement for “ongoing” care Fee Schedule for Visits/Procedures Payment per patient per month (or per year) for level of “Patient Centered Medical Homeness” Pay for Performance- Clinical and Patient Experience