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What is Clinical Informatics? | Predictive Analytic Modeling and ACOs Spring 2015

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Spring 2015 | Volume 26, No. 1 | www.azmed.org | facebook.com/azmedicine

IN MEMORIAM

David Landrith, ArMA VP of Policy and Public Affairs ..................... 6 FROM OUR PRESIDENT

ArMA Members and Grassroots Advocacy ........... 8

The Evolving Physician

The Rural & Urban Access to Health Program: Beyond the Bed, and Beyond the Room ............... 12 What is Clinical Informatics? ................................. 14 Predictive Analytic Modeling and ACOs ............... 16

The Evolving Physician: Where are we now? ....... 10

Tomorrow is Here: Educating Today’s Medical Students to Lead The Future of Our Profession .................................................. 18

SPECIAL SECTION: OPIOID Rx

Graduate Medical Education… and the ACA, NAS, VBP, P4P, HCAHPS, etc. ........ 22

EDITORIAL

The Arizona Controlled Substances Prescription Monitoring Program: An Invaluable Tool for Physicians .................... 30 PDMP Report Card: Will You be at the Top of the Class? ................ 32 Prevention is preferable to a cure .................... 34

Better information for better care and better outcomes through technology.................... 24 Are Physicians Evolving Into Shift Workers? ................................................ 26 HSAG VISTAS

Quality Improvement and Patient Safety: The Case for Physician Leadership....................... 28

Cancer Treatment Centers of America®

Patient Process

PASTORAL CARE SPIRITUAL SUPPORT PAIN MANAGEMENT

N I C H E A LT H R E C ORD CTRO ELE

RADIATION ONCOLOGY

CLINIC NURSE NURSE CARE MANAGER ONCOLOGY REHABILITATION

MEDICAL ONCOLOGIST ACUPUNCTURE ACUPRESSURE

PATIENT REGISTERED DIETITIAN

NATUROPATHIC PHYSICIAN MIND-BODY MEDICINE

TRAVEL AND SCHEDULING

ELE CTRO ORD N I C H E A LT H R E C

SURGICAL ONCOLOGY

CHIROPRACTIC CARE

Physician Referrals 623-207-3241

Step 1: Discuss your options Call a Cancer Treatment Centers of America® (CTCA) Oncology Information Specialist at 800-948-2279, available 24 hours a day. Step 2: Verify your insurance CTCA® will contact your insurance provider to verify your benefits and review the details of your insurance plan’s coverage with you. Step 3: Schedule an appointment After receiving insurance verification CTCA will schedule your initial appointment. In specific cases, you and your caregiver’s travel costs for evaluation are covered by CTCA. Step 4: Prepare for your visit CTCA will send you a personalized packet of information and an oncology nurse will call you directly to discuss your medical history and any questions or concerns you have. Step 5: Begin your evaluation Upon arrival, your medical team will review your health history and perform any diagnostic tests and procedures necessary. You will meet with your care team and have a personalized treatment plan. © 2014 Rising Tide

Spring 2015 | AZMedicine 5


thank you

TO OUR MEMBERS

You are the cornerstone of ArMA’s Legislative Advocacy. Being a member of ArMA ensures that you have a voice at the State Capitol and that you make a difference in medicine.


I

N

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M

O

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DAVID LANDRITH ArMA Vice President of Policy and Political Affairs April 18, 1947 – February 17, 2015 David Landrith, MPA, DHL, spent his life in service to good public policy for Arizona. From his early years as the Executive Director of South Eastern Arizona Governments Organization and throughout his 25 years at the Arizona Medical Association, where he was an advocate for physicians and patients, David saw the importance of how public policy could impact, and make better, the life of the individual. David earned his Masters of Public Administration from Harvard University, where he was a Dougherty Foundation Fellow. In 2014, A.T. Still University conferred upon David an honorary Doctor of Humane Letters degree, in recognition of his legislative and regulatory advocacy for medical professions in Arizona. David served on a number of boards throughout his career, including: Arizona Health-e Connection Board of Directors and Executive Committee, where in addition to being one of the founding members, he also served as Chair, Vice-Chair and Secretary; Health Information Network of Arizona Board of Directors and Executive Committee; Touchstone Behavioral Health Board of Directors; Arizona Town Hall Board of Directors; Arizona Biomedical Research Commission, where he also served as Chairman as well as Commissioner; Chair of Dean’s Advisory Council at ASU College of Extended Education; and as a member of the American Medical Association’s Advocacy Research Center. David was honored for his advocacy work many times throughout his career: receiving the Arizona Medical Association’s Distinguished Service Award in 2010; Outstanding Service Awards from the Arizona College of Emergency Physicians (2008) and from The Arizona Partnership for Immunization (2006); a Partnership Award by the Arizona Chapter, American Academy of Pediatrics (2002); and the Presidential Award from the Arizona State Association of Physician’s Assistants (1984). David worked on countless legislative and policy issues throughout his career, but he was most proud of his work on establishing, and more recently restoring, Medicaid in Arizona (AHCCCS), the expanded Medicaid program for children, SCHIP, and the strategy of incremental tort reform begun in the early 2000s. Additionally, David’s leadership and support of health information technology and health information exchange were unmatched. In his colorful and fulfilling personal life, David positively impacted the lives of countless people here and around the world. He touched many lives in so many uplifting ways, serving

as Mentor, Teacher, Career Counselor, Confidant, Life Coach, and of course, Tour Guide and Travel Consultant. David was an appreciative desert dweller – and traveler. Some of his favorite cities around the world included Vancouver, London, and Paris. From the canyons of the Sonoran Desert to the pure green of the British Isles, from the pristine, gleaming beauty of Turkey to hallowed, ancient Angkor Wat, from river boat tours in Russia to “crewing” on a repositioning sail cruise across the Atlantic Ocean, David let experience wash over him and absorbed lessons. One might say, he got living right: personally tough, generous, honorable, and committed; everything interesting, nothing excluded. Because of how he was put together, David Landrith was one of a small breed who are truly at home anywhere in this world. David relished policy work, was blissful with the delights of travel, but a friend describes him as “his best self” while traveling on foot, backpack stuffed for a week, through the beauties of the Colorado Plateau, the Mogollon Rim and the Sonoran Desert. David’s love of the good things in life – a meaningful conversation, a delicious meal, a gorgeous sunset, a beautiful song, a great scotch and a fine cigar, a memorable travel experience – was only exceeded by his desire to generously share those good things with the ones he loved. David was – by any measure – a man who lived life well, and to the fullest.

Spring 2015 | AZMedicine 7


FROM OUR

President

ArMA Members and Grassroots Advocacy As we await the decision of the U.S. Supreme Court in the King v. Burwell case involving the Affordable Care Act, we can say with certainty that the 2010 legislation marked the beginning, and not the end, of the reform process. Much about health care reform remains to be determined and developed, and we can see health reform activity unfolding through the direct work of additional legislation and indirect Congressional attempts to influence regulatory rulemaking. Because of the significant legislative controversy associated with the enactment of health reform and residual political acrimony, the importance and influence of physicians’ voices has increased. All politics starts locally, and that includes health care reform and regulatory ruleJeffrey Mueller, MD making. Both sides of the aisle now covet the participation and approval of physicians. Many in the Arizona House and Senate want to claim that the doctors are on their side. The Arizona Medical Association (ArMA) must actively engage our physicians’ grassroots voice in order to meet this demand for our participation in our state legislative and regulatory processes. You are the cornerstone of ArMA’s Legislative advocacy effort. That effort consists of three components. The first component is our professional representation team at the Capitol in Phoenix. They are our governmental “content experts” - constantly monitoring and interacting with all public officials, including members of the Legislature. Mr. Steve Barclay, our representative at the Capitol, and ArMA staff members work under guidance from ArMA’s Committee on Legislative and Government Affairs to ensure that ArMA’s overall advocacy effort is coordinated and effective. The second component is the collective political and campaign work led by the Arizona Medical Political Action Committee 8 AZMedicine | Spring 2015

(ArMPAC). The checks-and-balances of democracy demand that we develop and maintain political relationships with our legislative allies. ArMPAC is our mechanism for engaging in campaign work and facilitates the political portion of our First Amendment rights and responsibilities.

The Arizona Medical Association (ArMA) must actively engage our physicians’ grassroots voice in order to meet this demand for our participation in our state legislative and regulatory processes. The third component of our advocacy triad, direct grassroots advocacy by physicians, offers the most unique and effective tool for elevating medicine’s message above others. Grassroots advocacy occurs when physicians directly communicate their concerns with elected officials. There are two characteristics of constituent physicians that are highly valued by elected officials. First, they are potential voters and respected community leaders who can influence others, and therefore affect the legislator’s success on election day: the relationship dynamics upon which democracy is based. Second, the physician brings clinical credibility to the discussion. Members of the Arizona Legislature, bombarded by an almost unlimited number of


complicated issues and problems, highly value the earnest and sincere knowledge that a well-informed and trusted local physician can offer.

Successful communication with legislators requires both quality and quantity: detailed discussions carried out by professional staff and physician key contacts combined with a high volume of messages delivered by grassroots participation.

Physicians can take action in several ways as part of a grassroots advocacy involvement. The very first step is to be an ArMA member. ArMA members should also consider being an ArMPAC member. ArMA members may have the opportunity to serve as experts in testimony to legislative committees. And when a pressing call to action comes, ArMA uses our “STAT!” newsletter to request engagement by member physicians with their legislators.

Service as a key contact with a single legislator represents the other end of the grassroots advocacy spectrum. Key contact relationships with members of the Arizona legislature are developed over an extended period of time. They result from a long series of reliable, respectful phone calls, emails, letters, and meetings. Meetings in the local district are most effective, as the legislator will not be distracted by the constant Capitol activity of committee hearings and unpredictable floor votes. Occasionally, one gets a head start on a key contact relationship due to a coincidental relationship outside of politics, such as sharing a common alumni connection, social club, or when each other’s children attend the same school. The key contact’s primary goal is to become a trusted and reliable source of health care information. ArMA’s staff members and leadership are available to offer suggestions and guidance to those interested in growing their own key contact relationships with a State Senator or Representative.

out by professional staff and physician key contacts combined with a high volume of messages delivered by grassroots participation. Medicine must harness the substantial power of grassroots advocacy in order to effectively represent our profession and our patients. Regardless of your level of grassroots involvement, you’ll be doing very important and indispensable work for our profession and our patients. AM Jeffrey Mueller, MD, is the 123rd ArMA President. He is Associate Dean of Hospital Practice for Mayo Clinic’s 23 hospitals and Medical Director and a staff anesthesiologist at Mayo Clinic Hospital in Phoenix, AZ.

IT’S MORE THAN JUST FILLING VACANCIES

Successful communication with legislators requires both quality and quantity: detailed discussions carried

Short and long term provider coverage for: Vacation Medical leave CME Sabbatical Increased patient load

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www.catalinarecruiters.com It’s about matching lifestyles, personalities and practice philosophies. Spring 2015 | AZMedicine 9


EDITORIAL

The Evolving Physician: Where are we now?

Bruce Bethancourt, MD the next highest spending nation, Norway, but our life expectancy left us 24th on the same list of developed nations (Figure 1). The ACA is not a perfect solution, but much of its intent was to address problems in a “sick� care system that were not corrected by physicians or the health care entities in which we work. Because of the ACA, we now find ourselves in an era of the Accountable Care Organization (ACO), a vehicle that will drive the ACA and that focuses now on population health. The goals of the ACO are: better care for the individual, better health for the population, and lower 10 AZMedicine | Spring 2015

growth in expenditures.

Where are we going? Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. When we look at determinants and factors of health, we see health care, individual behavior, social environment, physical environment, and genetics. How much of these determinants do we as physicians have any control over? Models of population health management indicate that in order to improve overall patient outcomes, we need tailored health care interventions,

organizational interventions, and community resources. What we have today is fragmented sites of care in a system where patients face adversity in accessing care, little or no help in managing chronic disease, and a physician and provider community with no population health analytics to inform the system where these gaps in care are occurring. The ACA, in its own complicated, convoluted and bureaucratic way, is forcing our health care system towards a model that integrates health care across a continuum. (See Figure 2)

How can physicians evolve? With the passage of the ACA and focus on Population Health, there has not been such a transformational change in the profession of medicine since the time of Dr. William Osler. The medical profession

is at the beginning of this transformational change. Without meaningful physician leadership the true value of Population Health will never be realized. The traditional practice of medicine needs to transform to patient centered team based care. This can only effectively happen if physicians assume appropriate leadership roles at every point of care. The archaic top down or dictatorial leadership behavior of the past must be abandoned. Leadership is the ability to motivate others to do the right thing. Like it or not, we are leaders. Our success as physicians depends on our medical knowledge, how we apply that knowledge and how we lead other medical professionals as well as our patients and their families. As leaders, ships will

our relationdefine our

Figure 1 84

Life Expectancy

Healthcare Spending Per Capita

$8000

82

$7000

80

$6000

78

$5000

76

$4000

74

$3000

72

$2000

70

$1000

68

$0

Sw Japa itze n Au rland str aili a Ita l Ice y lan d Sp ain Fra n Sw ce ede Ca n nad N Ne orw a wZ ay Ne eala the nd rla n Au ds Ge stria rm Be any lgiu Ire m lan Gre d e Fin ce lan d Lux em UK Sou bou th rg Ko Por rea t De ugal nm ark Cze ch Re US pub Pol lic an Slo vak Mex d Re ico pu Hu blic nga Tur ry key

Prior to the Affordable Care Act of 2010 (ACA), the United States was not doing well on any scale of comparison with other developed nations. We spent nearly a third more on health care per capita than


success – relationships with our patients and with our health care team members. The attributes of successful relationships are respect and trust. Respect is developed and grows as you share experiences. After a number of successful shared experiences, you develop trust. Respect and trust are then maintained by integrity. Developing a successful professional relationship with the team of non-physician providers can improve the outcomes of not only your patient but all patients under their care (i.e. “high tide raises all boats”). The same is true with the professional relationship you have with fellow physicians, one with mutual respect and appreciation of the contribution they provide your patient. Several studies have shown that: • highly functioning care teams are associated with reduced mortality and decreased length of stay in hospital.1 • “relational coordination” reduced postoperative pain and increased postoperative function in patients undergoing hip and knee replacement.2

Physician-Patient Relationships Assuming the physician is technically proficient, his/ her interpersonal skills are critical to establishing strong, trust based physician-patient relationships. In a survey of

Figure 2

Care Access Coordination of Care Access to Care Retail Clinics CC Clinic

CAUTI CLABSI VTE Continuous Quality Improvement

Patient Centered Medical Home

Predictive Analytic Tool Financial Analysis Risk Stratification

Acute Care

Population Health Analytics Post Acute Care Alignment Coordination of Care

Preventative Health/ Chronic Disease Management

Case Management Nurse Navigators

Risk Asssessment Tools Quality Initiatives Process Improvement

patients conducted by the Mayo Clinic, patients identified seven key traits of an ideal physician and identified illustrative clues to those ideal physicians. It is no accident that we can easily see how these traits translate to successful leadership.

• Respectful – appropriately greets the patient with a hand shake upon entering the room

• Confident – not disturbed by patient queries from other medical sources

Physician-Community Relationships

• Empathetic – shares personal stories that are relevant • Humane – helps arrange non-medical assistance (e.g. Chaplain or social worker) • Personal – Remembers details about the patient’s life from previous visits. • Forthright – Doesn’t sugarcoat or withhold information.

Transitional Care Clinic

• Thorough – gives instructions in writing or offers to research literature on a difficult case3

The community plays an important role in either promoting or deterring health care. Physicians need to champion the effort to promote improved health care for all patients in our communities. The deterrence to medical care can be biological, social, or economic. It is important for us to develop relationships with organizations that can assist you in having a positive impact on medicine. This can

be accomplished by joining specialty societies, county and state medical associations such as the Arizona Medical Association. AM Bruce Bethancourt, MD, FACP, is Chief Medical Officer of Dignity Health Medical Group in Phoenix, AZ, and an ArMA past president. 1 “Association Between Implementation of a Medical Team Training Program and Surgical Mortality.” JAMA. 2010; 304(15):1693-1700. doi:10.1001/jama.2010.1506 2 “Impact of Relational Coordination on Quality of Care, Postoperative Pain and Functioning, and Length of Stay: A Nine-Hospital Study of Surgical Patients.” Medical Care, August 2000 - Volume 38: 8 - pp 807-819. 3 “Patients’ Perspectives on Ideal Physician Behaviors.” Mayo Clinic Proceedings: 2006, Vol. 81, Issue 3, 338–344.

Spring 2015 | AZMedicine 1


The Evolving Physician

The Rural and Urban Access to Health Program: Beyond the Bed, and Beyond the Room By Sherry Gray The Rural and Urban Access to Health (RUAH) program exists to connect our friends, family, and neighbors to a comprehensive, integrated delivery network of health, human and social services resulting in improved access and removal of barriers to needed resources. This program is “Beyond the Bed” (BTB) for hospitals; and “Beyond the Room” (BTR) for Physicians. It exists to connect the clinical work of providers and facilities to the community at large and viceversa. The work is based on the assumption that even the most excellent clinical diagnosis and treatment will never bring the outcomes anticipated and expected by Providers if the supportive needs of our most vulnerable population are left unmet. RUAH is program that is “assessment light” and “action heavy.” Any UN- (or under-) insured community member in the catchment zone are able to access the assistance of community based care 12 AZMedicine | Spring 2015

connection through a Health Access Worker (HAW). The program’s versions of Community Health Workers (CHW’s) are true Care Connectors. They act as Client Advocates and System Navigators. Their focus is to assure clients:

• Have access to, and are taking, the prescribed medications to manage their diagnosis; and

• Are attached to a Primary Care Medical Home

RUAH also employs Medication Access Workers (MAC’s)

• Have basic “wrap around”/ supportive services: Food, Clothing, Housing, Utilities, and Transportation.

The experience of this program has shown that Physicians get better results and patient outcomes when they have a team member who can assure that basic, fundamental “follow up and follow through” is addressed. • Are assisted through all requirements for reliability into and applicable federal, state and local programs • Have access to Specialty Care when indicated by the Primary Care Provider;

who order and maintain records of the prescribed medications for the clients on their work list. Since the program’s inception $58 million worth of low/no cost drugs (awp)

have been provided to Indiana citizens. RUAH has the goal of providing and increasing access the following way: • Right Care • Right Time • Right Place • Right Provider • Right Payer. Vital to this work is building trusted partnerships between the hospitals, clinics, providers and the community agencies that can help make the things listed above actually occur. Lessons learned? Hospitals and Medical Offices must learn more about the community in which they exist. They have to be more collaborative with the programs and services that are trying to meet the most basic needs of the communities’ vulnerable population. They have to adjust and make this a “team approach” with the community provider’s part of the team. They can’t just “refer” out; they have to be able to receive referrals from those same groups and work


to problem-solve together. For RUAH, the Health Access Worker has been the facilitator of this relationship and that has worked very well. Best Practice guidelines and productivity expectations, as well as documentation for the myriad of private and public payers have required so much time of the Provider that the context of his/her work with the patient holistically has been severely weakened. Simply put, Physicians do not have time to assess and assist with the needs of the patient beyond what is clinically indicated. They must be supported by a trusted team that can do that specific work. The experience of this program has shown that Physicians get better results and patient outcomes when they have a team member who can assure that basic, fundamental “follow up and follow through” is addressed. Ultimately the result should speak for them: • Un/underinsured community members receive care “sooner vs. later” • Consistent and familiar care is provided along with follow up and follows through • Treatment is across time and not episodic • Resources are used as effectively as possible, including: Human (Providers, Practitioners, Care Coordinators, Administrative support, etc.), Financial (reimbursement, funding,

The acronym, RUAH, is also a word in Yiddish meaning “Breath of Life.” RUAH wants to breathe new life into a Health care system that serves our most vulnerable community members compassionately, with quality and efficiency. cost-avoidance, “writeoff’s”), Technological • Information in is connected in a timely, meaningful way • Supportive (wrap-a-round) Services are provided to support the overall care plan • Medical treatment, public health practices, and psychosocial principles are integrated and connected • Vital connections are made • Integrated and coordinated care is not duplicative or repetitive • Vital partnerships are formed with the community Services, Programs, Agencies, etc. • “Best Practice” lessons are shared; and solutions are not “re-created” RUAH’s foundation was built from a community collaboration in 2000 between St. Vincent Health; Indiana Health Centers, Inc. (Federally Qualified Health Centers); Health and Hospital Corporation of Marion County (a county public health system); ADVANTAGE Health Plans, Inc. (a not for profit payer); and Butler College

of Pharmacy. Many other community partnerships and stakeholders were part of this initial program design: local church groups; local schools; county trustees; the YMCA; etc. The program was initially funded as a “pilot” through HRSA, and Ascension Health from 2001-2005; with additional funding added through the Anthem Foundation. The program is an AHRQ Innovation Site, a Community Care Coordination Learning Network Site, a National Institute of Health Research Partner, and a previous Indiana CHIPRA grantee. The acronym, RUAH, is also a word in Yiddish meaning “Breath of Life.” RUAH wants to breathe new life into a Health care system that serves our most vulnerable community members compassionately, with quality and efficiency. The outcomes speak for themselves. In the last calendar year, HAW’s have assisted 6,000 patients who were uninsured and had no primary care medical home. The reimbursement obtained for a study of 850 patients alone

resulted in $1.8 million dollars captured through Indiana’s Medicaid, and Healthy Indiana Plan enrollments. Well Child Visits compliance was increased to over 90% in one pediatric office specifically; and the “kept appointment” rate average continues to be maintained at or around 80% for the population served. A community care connection team does work and lofty goals start to see some forward movement: • Quality, evidence-based clinical care is provided consistently to all. • Become better stewards of existing resources: both human and financial. • Work with key partners and stakeholders to “own” this work together: as a community. • Demonstrate outcomes that make a real and observable impact (documented!). Sherry Gray serves as the Director of the Rural and Urban Access to Health (RUAH) outreach program with the St. Vincent Medical Group, and has been in that position since 2005.

Spring 2015 | AZMedicine 13


The Evolving Physician

What is Clinical Informatics? “So, what’s your new job? King of technology or something?” “Hey, you’re the medical director of informatics... I can’t get this word doc to print—can you fix it?”

Karl A. Poterack, MD The American Medical Informatics Association (AMIA) defines biomedical informatics as “the interdisciplinary, scientific field that studies and pursues the effective uses of biomedical data, information, and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health.”1 Nowhere are the words “technology,” “computers,” or even “electronic medical record.” The use of the word “informatics” in a health care context has only occurred since the 14 AZMedicine | Spring 2015

adoption of computers and electronic data storage and transmission in medicine. However, clinical informatics as such has been practiced since at least 1907, when Henry Plummer created a dossier medical record for patients at the Mayo Clinic, replacing the ledger based records in use at that time.2 Or maybe since 1895, when Harvey Cushing and E.A. Codman recorded the vital signs, anesthetic drugs and surgical events on a time-based graph that has been the format for anesthesia records ever since.3 Or actually, maybe since the 1860’s, when the daily temperature charts of hospitalized patients first appeared that were probably the inspiration for Cushing and Codman’s anesthetic charts.4 All of these things were important, not just because they were novel ways of storing and presenting data, but because they allowed relationships between data to be readily apparent, and thus could facilitate changes in clinical care and workflow. Today, Clinical Informatics is an ABMS-recognized subspecialty, i.e. candidates must already be board certified in a

primary specialty by one of the ABMS’ 24 member specialty boards. Board certification in Clinical Informatics was first offered in 2013 and there are currently 785 boarded informaticians.5 Most of them qualified to take the boards by meeting the requirements of the practice pathway (“grandfathering”); after 2018, eligibility to take

possible, using that information to build knowledge, and then getting the right information and knowledge to the clinician at precisely the right time. When this occurs, not just patient care but population health is optimized. The more seamlessly it all occurs, the more ideal clinical workflow is produced. Certainly, computers and technology can

Clinical Informaticists, by virtue of being trained clinicians with additional expertise in informatics, are uniquely positioned to be the “bridge” between the clinical world and the IT world. the CI boards will be based on completion of an ACGME accredited fellowship.6 Clinical informatics is not really about computers or technology so much as it is about collecting the right information as seamlessly as

facilitate this. Unfortunately, they usually don’t. Far too often the “computers” force clinicians to click thru meaningless screens, divert their attention from the patient, and otherwise detract from clinical care rather than enhance it. It is a sad reality that inpatient


RNs have reported spending more time with “the computer” than with the patient.7 This state of affairs is one that should not be accepted. The disrupted workflows and detractions from care referenced above are not an inherent result of “computers,” but of a design process uninformed by the realities and needs of clinical care. Clinical Informaticists, by virtue of being trained clinicians with additional expertise in informatics, are uniquely positioned to be the “bridge” between the clinical world and the IT world. The needs of the clinical practice can be met while the constraints of the hardware and software systems are taken into account. Those of us in informatics

often think of ourselves as “translators”; while most of us (me included) don’t actually code software, we can speak the languages of both the clinical side and the IT side and are able to articulate the requirements of clinical practice to those who do code the software. Clinical Informaticists are also in a position to leverage the vast body of knowledge on user-centered design, human computer interface, and machine learning that has been used for decades in other fields but up till now not so much in health care. If ordering a product from Amazon. com were as difficult as using an EHR, that company would have gone bankrupt long ago. While it won’t happen

overnight, informatics can and should help make using an EHR more intuitive and less dependent on hours of training. So, no, clinical informaticists are not here to fix your printer or upgrade your iPhone. However, we may be able to help you tune your EHR to work with you rather than against you. AM Karl A. Poterack, M.D. (poterack.karl@ mayo.edu) is board certified in Anesthesiology and Clinical Informatics. He practices at Mayo Clinic Hospital in Phoenix, Arizona and serves as Medical Director, Applied Clinical Informatics for the Mayo Clinic Office of Information and Knowledge Management. 1. “What is informatics?” http://www.amia.org/ retrieved on 2/11/2015

tradition-heritage/medicalrecords.html retrieved 2/11/2015 3. “History of Anesthesia Records” Gerald L. Zeitlin, http://www. woodlibrarymuseum.org/news/ pdf/Zeitlin.pdf retrieved on 2/11/2015 4. “Vital Signs and Resuscitation, Joseph V. Stewart, p. 15 http:// www.webpal.org/SAFE/aaarecovery/7_medicine/Medicine%20 -%20Severe/Vital%20Signs%20 and%20Resuscitation.pdf retrieved on 2/11/2015 5. http://www.amia.org/ clinical-informatics-boardreview-course/2014-diplomates retrieved on 2/11/2015 6. “The American Board of Preventive Medicine Clinical Informatics Board Certification” http://www.theabpm.org/ applicationci/ci_requirements.pdf retrieved 0n 2/11/2015 7. Kossman SP, Scheidenheim SL. Nurses’ perceptions of the impact of electronic health records on work and patient outcomes. Comput Inform Nurs. 2008;26:69-77.

2. “Medical Records at Mayo” http://www.mayoclinic.org/

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Spring 2015 | AZMedicine 15


The Evolving Physician

Predictive Analytic Modeling and ACOs Accountable Care Organizations (ACOs) may be a transitional model in the evolution of the US Healthcare Systems, but the fundamental tenants of population health management will endure for

Keith A. Frey, MD, MBA

decades to come. Knowledge of the patient population attributed to an ACO, including demographic, clinical and financial data, is critical. Patients with chronic diseases – both manifest and indolent (so called, ‘rising risk’) – require active surveillance and multidisciplinary care interventions. The ability to identify, partner with, and manage these cohorts of patients requires new care designs and technology tools. One

such

emerging

16 AZMedicine | Spring 2015

technology, healthcare predictive analytic modeling, comes from the scientific discipline of Biomedical Informatics. Predictive analytics is a blend of techniques and tools that enable organizations to identify patterns in data that can be leveraged to make predictions of future outcomes. In healthcare, data and information derived from clinical sources (e.g. labs, imaging, medication, and physiologic), resource utilization (e.g. claims data, supply chain and other costs), and social and behavioral health determinants is used for such modeling. In the conceptual framework depicted in figure 1, using a predictive analytic tool, the population is assessed and risk stratified along a care continuum from low, moderate to high risk. Once the patient is identified along the care continuum specific interventions, such as health promotion and wellness, risk management, care coordination, and disease/ case management can be appropriately implemented. This approach allows the physician and the organization to focus appropriate resources

Predictive analytics is a blend of techniques and tools that enable organizations to identify patterns in data that can be leveraged to make predictions of future outcomes. on patients with the greatest need. Outcomes of these interventions are measured and a continuous quality improvement is implemented. As an example, in July 2014 Dignity Health announced a partnership with business analytics leader SAS to collaborate on a next generation analytics platform, “Dignity Health Insights” by standing up a secure, cloud-based “Enterprise Data Warehouse.” Under the leadership of Dr. Joseph Colorafi (Chief Medical Information Officer), Dignity Health and SAS have established an exceptional cross-functional team comprised of industry experts in

various areas of Healthcare, Big Data, and Analytics. Early initiatives include: • CHF (Congestive Heart Failure): Predicting and reducing readmission of patients with CHF • Sepsis Biosurveillance: Help reduce mortality rate in Dignity Health hospitals caused by severe Sepsis infections • Pharmacy Analytics – reporting solution to help create and evaluate pharmacy operations, leading to cost reductions The automation of the healthcare industry has been challenging. The insertion of


Figure 1. Conceptual PHM Framework Population Monitoring/Identification

Health Assessment

Risk Stratification

Care Continuum No or Low Risk

Moderate Risk

High Risk

Health Management Interventions Health Promotion, Wellness

Health Risk Management

Organizational Interventions (Culture/Environment)

Care Coordination/ Advocacy

Disease/Case Management

Tailored Interventions Person

Community Resources Operational Measures

Program Outcomes Psychosocial Outcomes

Behavior Change

Clinical and Health Status

Productivity, Satisfaction, QOL

Financial Outcomes

Source: Care Continuum Alliance, Outcomes Guidelines Report, Vol. 5, 2010

electronic medical records in busy ambulatory clinics, emergency rooms, and hospitals has highlighted the necessity to mature these software

solutions to better accommodate the clinical workflows of doctors, nurses, and allied health staff. Yet, the increasing opportunities to retrieve

This approach allows the physician and the organization to focus appropriate resources on patients with the greatest need.

and analyze the now available clinical data create new opportunities to improve outcomes. As physicians, we have a shared vision of improving the health and healthcare of our patients, their families, and their communities. Advancing technologies, like predictive analytic modeling, will allow us to identify illness burden earlier, intervene effectively, and use healthcare resources more efficiently. AM

Keith A. Frey, MD, MBA is Chief Physician Executive for Dignity Health Arizona, and President, Dignity Health Medical Group in Arizona. He is board certified in both Family Medicine and Clinical Informatics.

Winter 2014 | AZMedicine 17


The Evolving Physician

Tomorrow is Here: Educating Today’s Medical Students to Lead The Future of Our Profession Like so many young physician colleagues now out in practice, I began my career with the confidence and enthusiasm of someone on the cutting edge of academic and clinical medicine. Armed with a stellar

Jennifer Hartmark-Hill, MD Mayo Clinic training and a U of A Faculty Development Fellowship, I was excited to pass on knowledge and skills from my mentors to my medical students. But then, suddenly, a tsunami of change swept over the medical profession. The Affordable Care Act was passed into nebulous reality, Accountable Care Organizations sprang up seemingly overnight, and more physicians had to change the way they practiced, or simply 18 AZMedicine | Spring 2015

closed their practice doors. To keep current with the many changes, I found myself learning real-time in order to be able to share relevant information about our ever-changing healthcare system. Today’s medical students will be far more likely to be employed by large organizations, quality measures will be imperative, and clinicians will need to collaborate with interprofessional teams to deliver care. So then, how do we educate our future generation of physicians to be prepared for the next landscape of medical practice when it seems the sand shifts under our feet daily? Although we cannot anticipate all of the changes that are sure to come, we can equip our students to be adaptable, resilient leaders and patient advocates. If we are to be successful, the following three areas are among those that are key – team-based patient care, leadership and advocacy.

Team-based Patient Care In response to the gap between quality and safety benchmarks

Although we cannot anticipate all of the changes that are sure to come, we can equip our students to be adaptable, resilient leaders and patient advocates. and the patient data, the Institute of Medicine has called for interprofessional team care to improve access to care and to improve the chasm between current data and optimal patient safety standards.1,2 Nationally-consistent, standardized and evidence-based curricula have lagged despite a strong call for change. To address this need, in July of 2013 the Liaison Committee on Medical Education (LCME) released a common standard for Interprofessional Education (IPE).3 Other healthcare professions now mandate IPE curricula as well. Today’s medical students are now being prepared to enter a healthcare reality that must

be team-based. In a significant paradigm shift, medical students are being educated and, in essence, “growing up together” with the interprofessional healthcare student peers that will someday comprise their patient care team— nurses, physician assistants, social workers, pharmacists, dietetics, speech therapists and many others. Our medical students are being taught core competencies of interprofessional collaboration, including value and ethics for interprofessional practice, interprofessional communication, roles and responsibilities, teams and teamwork.4 Future healthcare providers will have Continued on page 20


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Medical Student Perspective Do you feel your training and experience has helped you develop a sense of “professionalism” of feeling and thinking and acting like a physician? As a physician, do you feel that part of your identity is to be a leader? I distinctly remember the first time I felt like I could make a decision about how to care for a patient: I was working with the lone ER physician in an overrun rural ED. My patient had slammed his thumb in a car door and it had since taken on the shape and color of a gnarly hot dog. I chose to get an x-ray, and immediately panicked about the appropriateness of that study.

Calliandra Hintzen

One of my favorite attendings in medical school is in the habit of asking, “If I weren’t here, what would you do?” It places the onus of decision-making back on the student and serves as a valuable reminder that one day, he won’t be there to double-check my workup or my treatment plan. Mid-way through my clinical training that question became less of an academic exercise so much as a personal mantra, a mental check to see how robust I thought my plan was. When I wrote my daily A/P, was I truly confident enough to enact it? If there were no resident and no attending, is that how I would treat my patient? Until I felt the weight of that responsibility, “professionalism” was little more than a scholastic buzzword, most commonly invoked to enforce a dress code. My training forced me to confront the reality of what it meant to think like a doctor and motivated me to practice being the kind of physician I hoped to become. I began to notice what set apart the attendings I saw as role models—the way Dr. N conveyed urgency without raising her voice, the way the OR staff were excited to be assigned to Dr. P’s case because he was a pleasure to work with. Many of us are drawn to medicine because we want to be shot-callers, so to speak. But I think most of us develop our sense of professionalism and come to leadership through conscious reflection on our clinical experience— we look at the kind of decisions doctors face and think, “What kind of person would I want making those choices about my care? My grandmother’s care?” Responsibility is given to us, but that doesn’t mean we’re born leaders. Instead, we choose who we emulate and try really hard to be someone worth following. Calliandra Hintzen M.D. Candidate, Class of 2015 University of Arizona College of Medicine-Phoenix hintzen@email.arizona.edu

20 AZMedicine | Spring 2015

Tomorrow is Here Continued from page 18

the foundational knowledge and communication skills to collaborate in a crossculturally competent manner with regard to other healthcare professions. A growing body of literature is available to teach students the interprofessional and team-based care models that increase efficiency, decrease cost, improve patient outcomes and patient safety, and utilize continuous quality improvement analysis for ongoing advancement toward

improvement and other “business of medicine” topics are increasingly being recognized for their value in better preparing the physician of the future, along with monitoring patient satisfaction, clinician-team communication and interpersonal dynamics are critical to achieving optimal results for patients.

Leadership Physicians in the 21st century assume a diversity of roles, including educator, advocate, innovator, investigator and administrator.6 Thus, medi-

Although we cannot anticipate all of the changes that are sure to come, we can equip our students to be adaptable, resilient leaders and patient advocates. patient-centered outcomes.5 Likewise, promotion of prevention (primary, secondary and tertiary) across all specialties must be promoted for best patient outcomes. Models such as those that utilize a strong primary care base, integrated behavioral health, collaboration and communication between PCP and subspecialists, improved transitions of care at hospital discharge are evidence-based and should be taught. Financing of healthcare systems, continuous quality

cal students should be given early exposure to diverse career pathways, and educated with a foundation to prepare them to seek involvement and leadership as such. As leaders, future physicians will find the old hierarchical system less relevant to achieve desired outcomes, and should be trained with professional identity formation as 360 degree leaders. As such students will be ready to act in a concentric circle model to influence those in every role around them, from clinician


colleagues to non-clinician healthcare workers to health system administrators and policymakers alike. Furthermore, if we are to protect the patient-centered practice of medicine into the future, we must inspire and equip our future physician-leaders to serve in all roles which impact delivery of care, from the business of medicine to political advocacy and healthcare policy and beyond.

Advocacy The need for physician leadership roles has evolved and diversified, so advocacy must be taught and promoted in a multifaceted approach. Students need to learn the significant impact that state and federal legislators have on scope of practice and quality of patient care, and learn how to educate those who make

of funding (or cuts thereof) determine de facto policy, will affect patient outcomes. Classroom didactics, as well as early involvement of students in organized medicine and specialty societies, will inform professional identity development and provide role models who are active in advocacy efforts.

Conclusion Although medical education and patient care may have surprisingly new and different packaging than when we went through our training, the core values of our Profession have not changed. Wherever our teaching journey takes us, whatever modalities and technology arise, and whichever collaborative interpersonal dynamics frame our endeavors, the best interest of the patient is always to be

Although medical education and patient care may have surprisingly new and different packaging than when we went through our training, the core values of our Profession have not changed. laws that affect patients. They must recognize multifaceted opportunities for advocacy, such as with state agencies, where decision-making oversight and distribution

considered. It is essential to our integrity as physicians. It is also common ground with our interprofessional colleagues. This is the challenge and the opportunity we have before

us— we must teach the future generations of physicians to be patient advocates and leaders and to use their extensive training as physicians to empower those around them toward an environment of best outcomes in patient and population healthcare. In the face of challenges new and old, generation by generation, it is up to us to ensure fidelity to this calling. AM Dr. Hartmark-Hill is Faculty at the University of Arizona College of Medicine-Phoenix where she serves as Director of the Capstones Course, which provides early clinical experiences to first and second year medical students. She is also the Director of the Program of Narrative Medicine and leads the Creative Writers’ Group. References 1 Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2 Institute of Medicine. Health Professions Education: A Bridge to Quality. Washington, DC: National Academies Press; 2003.

3 LCME Liaison Comittee on Medical Education. Proposed new accreditation standard ED-19-A. http://www.lcme.org/ new_standard_ed-19-a.htm. Published October 2, 2012. Updated February, 2013. Accessed February 15, 2015. 4 Schmitt M, Blue A, Aschenbrener CA, Viggiano TR. Core competencies for interprofessional collaborative practice: Reforming health care by transforming health professionals’ education. Academic Medicine. 2011;86(11):1351. 5 Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: Effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013;3:CD002213. 7 Irby, David M., Molly Cooke, and Bridget C. O’Brien. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 2010; 85(2): 220-227.

Spring 2015 | AZMedicine 21


The Evolving Physician

Graduate Medical Education…and the ACA, NAS, VBP, P4P, HCAHPS, etc. “…If your time to you Is worth savin’ Then you better start swimmin’ Or you’ll sink like a stone For the times they are a-changin’...” — Bob Dylan By Charles C. Daschbach, MD, MPH, and T.C. Cossey, MD Today’s Physician Evolution is perhaps better characterized as a “Turbulent Revolution” in Graduate Medical Education (GME) and Teaching Hospitals. The residency

rates, with 110+ hour weeks, and every third night on call. In July 2014, the Accreditation Council for Graduate Medical Education (ACGME) installed a new accreditation system with sweeping changes that go far beyond the 2003 requirement for limiting duty

hours to 80 hours a week and a continuous 24 hour limit.

As the Teaching Hospital itself faces external changes in reimbursement tethered to its quality and outcome measures, it becomes paramount to evaluate how GME contributes to those outcome measures and how we can teach residents to incorporate these changes into their education. This change is amplified because most teaching physicians are not as facile with the new world order of Value-Based Purchasing, HCAHPS patient experience measures, and 30-day readmission penalties.

The “Next Accreditation System,” or NAS, refocuses all residency training in a new internal framework that

Teacher and Learner are both equally challenged to adapt across the spectrum of caring for individual patients

The expectation is for residency programs to demonstrate alignment with the sponsoring institution’s quality goals and objectives. program that physicians remember with fondness bears little resemblance to our older training emphasis on number and types of clinical cases and board certification passing

22 AZMedicine | Spring 2015

emphasizes how GME contributes to quality improvement, patient safety and transitions of patient care. The expectation is for residency programs to demonstrate alignment with the sponsoring i n s t i t u t i o n ’s quality goals and objectives. while receiving aggregate quality reports, trending graphs of core measures and quality dashboards. There are many facets to this challenge and some have come to the forefront: • QUALITY and PATIENT SAFETY Physicians have always taught and demonstrated quality in patient care at the bedside, but we have not documented it well. Today’s expectation is for physician team leadership in understanding the nature of Quality Improvement. This includes the PDCA cycle, Fishbone Diagrams, Run Charts and a better appreciation of the strengths


and inherent weaknesses of statistical data. • COMMUNICATION We always had ways to “hand off” patients as Interns and still do today within Medical Groups and with Consultants. Now we must document how we do this as to not lose important clinical and social information. Systems have evolved with acronyms and electronic schematics that mandate uniform processes from covering patients overnight to transfers from the ICU and discharge planning. No more 3 X 5 cards… Physician–Patient Communication is now rated in direct feedback from patients on how well we explained our clinical finding and plans, managed pain, and prepared a patient for discharge.  A key problem remains in terms of “Physician Attribution.” A physician of record is still named in the average Costs, Lengths of Stay, Outcomes and even Patient Satisfaction, regardless of how many other physicians, consultants, interns, residents and medical students were part of the care team. • POPULATION HEALTH Physicians have also traditionally looked to the broader perspective of their practice and how well we have managed our own population. Now with the ACA’s Accountable Care Organizations (ACO)

For all the administrative paperwork, limitations of hours, surrogates of quality, and government regulations, there still remains a patient and a doctor in a room or at the bedside. we have resurrected the capitation model and added aggregate quality measures that will directly affect reimbursement. Most physicians and hospitals are not well equipped to move from the acute care model to one focused on preventive care and wellness, although several specialties have always held this as a prime philosophical tenet of their mission.

• PROFESSIONALISM Perhaps a most challenging change in teaching medical students and residents today is instilling the sense of vocation that drew us all into a career of caring and healing. As Robert Zimmerman (Bob Dylan) noted in his clarion call to a previous generation, we have now become our parents and need to look forward rather

than pontificate and lament about the “old days.” We need to prepare the current students, residents and new graduates for the changes they will face far beyond the ones on our horizon. For all the administrative paperwork, limitations of hours, surrogates of quality, and government regulations, there still remains a patient and a doctor in a room or at the bedside. That is the greatest lesson we can share within the next generation of physicians. The privilege of trust given from a human being to another, like no other in our world. AM Dr. Charlie Daschbach is Director of Academic Affairs and Dr. Tiffany Cossey is a Senior Resident in Adult Neurology at St. Joseph’s Hospital and the Barrow Neurological Institute.

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Spring 2015 | AZMedicine 23


The Evolving Physician

Better information for better care and better outcomes through technology Physicians today are facing unprecedented change in compensation and reimbursement. The move from volume-based to value-based payment in arrangements such as ACOs, patient-centered medical

Melissa Kotrys, CEO, Arizona Health-e Connection homes or shared savings arrangements will require a new level of care coordination and data analytics. Physicians will be required to lead highly efficient teams, coordinate care across settings and among multiple providers, and utilize community data and evidencebased practices to improve quality and patient outcomes. The last time that the provider community faced radical change in compensation was in the capitated payment approaches of the 1990s, an

24 AZMedicine | Spring 2015

experience that wasn’t popular with patients and was even less so with physicians. So, it would be fair to ask, what is different about today? The answer is that we have new technology – electronic health records (EHRs) to support highly efficient team-based care and health information exchange (HIE) to integrate information from multiple sources – to better coordinate care and improve outcomes.

EHRs and a HighEfficiency Team Today, more than 80% of Arizona providers have adopted and are using some form of an EHR, and most of these are meeting the Meaningful Use requirements of the CMS EHR Incentive Program. Meaningful Use does not generate new information or data. From demographics to problem lists to allergies and medications – these types of data have always been basic to modern medical practice. What Meaningful Use does is require that this data be digitized and structured so that information can be more readily available and securely shared within the practice and

with other providers outside the practice. This structured data is not only more accessible for managing patient care, it also can help a provider understand and assess the risk level of his patient population, a basic requirement for participation in shared savings arrangements. Perhaps the most critical contribution of EHRs is that information previously collected by physicians can now be captured and entered by other staff members. While physicians still must oversee the process to verify the accuracy of the data, EHR adoption allows physicians to delegate many clerical and administrative tasks that they once performed. This shifting and delegation of tasks is at the heart of practice transformation that typically involves a review of the practice’s workflow so that the segments of a patient encounter can be managed by various staff members, with the EHR becoming the center of the practice where patient information is captured and shared. A number of other Meaningful Use requirements such as e-prescribing and medication

reconciliation drive additional efficiency in the practice. The result is improved efficiency and increased productivity, especially for the physician who is able to dedicate a greater portion of his or her workday to direct patient care.

Statewide Health Information Exchange (HIE) To Coordinate Across Health Systems Depending on where a practice is located and affiliated, there may be a number of options for securely sharing patient information with other providers through EHRs or through enterprise or private HIEs. AzHeC, through The Network (Health Information Network of Arizona – HINAz) offers Arizona’s only statewide HIE that enables the secure sharing of patient health information across health systems and communities. Last year, AzHeC and The Network combined operations and began a process to upgrade the technology for the statewide HIE platform. The result was the selection of the Mirth Corporation to provide The Network’s new HIE platform and support its new HIE services.


In addition to continuing The Network’s service offerings of bidirectional health information exchange and a secure online portal, the new services available in 2015 will improve care coordination and interoperability across health care systems and among health care providers throughout the state. Four new service offerings in this technology upgrade include: • Direct Secure Email – This HIPAA compliant, encrypted, standards-based application enables secure messaging between Network participants and providers for point-to-point sending and receiving of routine information such as referrals, simple clinical messages and test results. • Alerts and Notifications – Admission-dischargetransfer (ADT) alerts and other clinical notifications let providers know in real time that an ADT event has happened or a specific result has been received. The available alerts include hospital emergency department (ED) registrations, inpatient admissions, hospital and ED discharges and ambulatory registrations. The available notifications include lab, radiology and transcription results and reports. • Public Health Reporting – This service provides a single connection or electronic gateway for Network participants to submit state and federally required

Perhaps the most critical contribution of EHRs is that information previously collected by physicians can now be captured and entered by other staff members. public health information from a certified EHR system. The types of gateways will include immunization registry, syndromic surveillance, reportable lab results and reportable diseases • eHealth Exchange – This service will allow for the secure electronic exchange of patient information via the national eHealth Exchange network. The eHealth Exchange connection will allow Network participants to discover patient records, query and receive health information and share documents on their patients with HIEs in other states and federal agencies such as Indian Health Service, the Department of Veterans Affairs and Social Security Administration.

Arizona’s only statewide HIE to improve care coordination and quality through the secure sharing of patient information. We are proud to have assisted Arizona providers with Meaningful Use and practice transformation, and we are

excited to offer these new HIE services to help providers with better information for better care and better outcomes. If you have questions or would like to learn more about the statewide HIE services of The Network, please contact us at (602) 688-7200 or thenetwork@azhec.org. AM Melissa Kotrys is the Chief Executive Officer for Arizona Health-e Connection (AzHeC) and the Health Information Network of Arizona. AzHeC operates the Arizona Regional Extension Center, which assists Arizona providers in achieving Meaningful Use.

AzHeC, through the Arizona Regional Extension Center (REC), has assisted more than 3,000 Arizona providers with Meaningful Use and practice transformation. Through The Network, AzHeC offers

Spring 2015 | AZMedicine 25


The Evolving Physician

Are Physicians Evolving Into Shift Workers? The Affordable Care Act (ACA) has transformed the health-care delivery system. It envisions (and mandates) coordinated care, population health management, and a reduction in “unnecessary”

Paul J. Giancola, JD and duplicative medical services. The goal is improved quality of care at lower cost. The ACA has already resulted in a large drop in the uninsured population. According to The New York Times, before the ACA, there were 42 million uninsured. Now there are 29 million uninsured with a net gain of over 13 million new patients added to the health-care delivery system. The gain in insured patients is attributed to the ACA exchanges, Medicaid expansion, more people buying insurance directly from

26 AZMedicine | Spring 2015

insurers and people who were already eligible for Medicaid but are now actually signing up for it. The reduction in the uninsured population has also occurred despite 22 states declining to expand Medicaid. Unless the Supreme Court or Congress derails the ACA, the likelihood is that people will continue to sign up for insurance on the exchanges and those states that have not embraced Medicaid expansion will find a way – perhaps with conditions – to accept the available federal money to extend public health-care to more of the poor. States that have accepted Medicaid expansion have found that the federal money provides for increased employment in healthcare and a more robust state economy. As states embrace Medicaid expansion, the goal of the ACA to expand insurance coverage and access to healthcare to 32 million citizens may eventually be realized. At the same time that the insured population is expanding, the aging population eligible for Medicare will grow by 36 percent in the next few years. When taken together,

the expansion in the insured population and in the over 65 population has and will continue to substantially expand the demand for physician services. Expanded insurance coverage alone is estimated to increase the number of annual primary care visits by 60 percent. According to one study, this increase alone will require between 4,000 – 7,000 additional primary care physicians per year. Looking down the road, the Association of American Medical Colleges (AAMC) estimates that the United States will face a shortage of more than 130,000

physicians in ten years with the shortage of physicians evenly divided between primary care and specialists. The goal of integration and coordination of care under the ACA has resulted in new models of care delivery and payment. Fee-for-service payment is declining. The government and commercial payors are rapidly moving toward bundled and shared savings incentive programs that are designed to be more efficient and generate cost savings. The President’s recent budget proposes to squeeze $400 billion over the next 10 years out of federal healthcare


programs. In part, to accomplish this goal, CMS intends to require that 30 percent of Medicare payments are made through alternative payment models by 2016 and 50 percent by 2018. To serve these ACA models of care, hospitals have acquired primary and specialty medical practices at a rapid rate. At the same time, hospitals are hiring new physicians and recruiting physicians from specialty practices. Many physicians and group practices not wanting to be left behind are approaching hospitals asking for employment. For insurers, consolidation and integration of care means fewer contracts to manage and the possibility of more coordinated patient care – rather than isolated services. For hospitals with robust physician panels, it means having more influence in negotiating contracts. Physicians, however, are caught in the middle. At one time, physician practices consolidated and grew larger so could capture ancillary revenues through ambulatory surgery centers and in-office ancillary services such as imaging, physical therapy, and laboratory. However, as hospital employees, physicians are generally paid a salary and they are expected to be productive and the hospital captures the ancillary revenues. With more patients to see, and hospitals seeking to be profitable by spending less on care under the new payment models,

hospitals and insurers will be the controlling parties in determining the future of the health-care delivery and payment system. Time will tell whether the United States reaches the goals of the ACA – to improve qualify and access with less cost.

Today over 60 percent of primary care and over 50 percent of surgeons are employed by hospitals. it often means physicians have to see more patients in less time while reporting to hospital administrators and following hospital imposed practice guidelines. Not surprisingly, most physician hospital employees still report working 10 hours per day plus having on-call obligations. Today over 60 percent of primary care and over 50 percent

of surgeons are employed by hospitals. The trends of decreasing fee-for-service payments to physicians and increasing hospital employment will likely continue. As employed physicians become less involved in developing new models of payment in which they are an equal partner at the negotiating table, the government,

A byproduct of these goals is continued physician employment by hospitals along with loss of autonomy. AM Paul J. Giancola, JD, is a partner in the Healthcare Practice Group, Snell & Wilmer, LLP, Phoenix, Arizona.

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Spring 2015 | AZMedicine 27


HSAG Vistas

Quality Improvement and Patient Safety: The Case for Physician Leadership “ There is nothing in a physician’s education and training that qualifies him or her to become a leader” — L.L. Mathis from “The Mathis Maxims: Lessons in Leadership” By Howard Pitluk, MD, MPH, FACS & Mary Ellen Dalton, PhD, MBA, RN Our increasingly complex healthcare delivery system has drastically altered the way physicians practice medicine in the 21st century. A number of external forces have forever transformed physician autonomy and the hierarchies in which they practice. These include demand for public accountability in patient safety, better quality and efficiency of healthcare delivery, and public access to medical information. For individual physicians, flexibility of practice is being supplanted with standardized evidence-based guidelines, while multiprofessional teams have become the new model for care that supersedes the old paradigm of an individual’s blend of art and science as the be-all and end-all in patient

28 AZMedicine | Spring 2015

care. To master this changing healthcare paradigm, physicians must evolve beyond their traditional role in the care continuum of “captain of the ship” and become healthcare team leaders, embracing the changing technology in electronic health records, patient communication, and public reporting of quality measures. To become effective leaders, physicians must move away from individual thinking and toward systems thinking, which focuses on the impact our decisions and work will have over time and beyond individual contexts.

The New Healthcare Landscape As the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) in Arizona, Health Services Advisory Group (HSAG) works with physicians and healthcare providers in hospitals, nursing homes,

individual practitioner offices, and multiple community settings. HSAG’s mission to improve patient safety and clinical outcomes incorporates goals grounded in evidence-based guidelines that include the reduction of healthcare-associated infections and conditions by 40 percent; reduction of hospital

through self-management and education. Central to these efforts is the physician as opinion leader, bringing about change through personal accountability, while leading by example and motivating colleagues, patients, and organizations to take responsibility for processes that produce the desired outcomes.

Ultimately, all aspects of care management will need to be integrated into a delivery system that is responsive to population health while remaining patient-centered.

readmissions by 20 percent; and elimination of adverse drug events, falls, and pressure ulcers in our nation’s nursing homes. These goals also specify adherence to evidence-based guidelines that control blood pressure, decrease heart attacks and strokes, and address diabetes

Physician Leadership Healthcare needs physician leadership that is inspiring and collaborative. In a 2011 Harvard Business Review article, John Abele wrote that collaboration is a natural by-product of leaders who are passionately curious, modestly confident, and mildly obsessed. These


leaders seek new insights from others, do not turn collaboration into competition, and are focused on the collective mission. Abele adds that collaboration “may be the only leadership model that produces breakthrough results.” This transformational leadership looks for ways to motivate followers with a view to engaging them more intimately in the work process, leading to performance at or beyond expectations. The National Quality Strategy (NQS), which was mandated by the Affordable Care Act (ACA), can help physician leaders shape their strategies as they define their role within the healthcare team. NQS priorities call on healthcare leaders to make care safer by reducing harm and ensuring that each patient and their family members are engaged as partners in their care. Healthcare leaders are also being called upon to promote the most effective prevention and treatment practices for the leading causes of mortality, such as diabetes and cardiovascular disease. Some of the greatest opportunities to influence and improve care often happen outside of the physician office, such as in churches and community centers. Physician leaders can bring together resources from primary care, public health, and the community to address major population health issues. In turn, partnering with communities can promote the wide use of best practices and enable

To become effective leaders, physicians must move away from individual thinking and toward systems thinking, which focuses on the impact our decisions and work will have over time and beyond individual contexts. healthy living. Ultimately, a leadership approach that helps develop and spread new healthcare delivery models and makes quality care more affordable for individuals and their families will result in better health for populations and communities. The NQS also reflects healthcare’s shift from a disease model to a wellness model where patients are no longer on the sidelines of care but instead are at the center. This patient-centered strategy can be difficult to implement and coordinate as patients often receive health-related services at numerous sites outside of the doctor’s office, such as hospitals, nursing homes, or at home. Therefore, physician leadership is essential in order for providers to engage with each other and ensure patients receive quality care across this continuum. This coordination is especially important as the ACA requires that all healthrelated stakeholders become accountable for patient care, which in turn will be linked to quality reporting and payment.

Ultimately, all aspects of care management will need to be integrated into a delivery system that is responsive to population health while remaining patient-centered. HSAG is a no-cost resource available to help physicians meet the challenges of the new leadership requirements, including managing chronic disease, reducing infections, and implementing health information technology. Whether in hospitals, physician offices, or community health centers, HSAG focuses on quality improvement efforts that strive to enhance care in the local setting by enabling physicians to learn useful tools, gain insight from shared experiences, and assume leadership roles in their practice venues. These efforts are essential for the healthcare transformation taking place in our country to succeed.

improvement model that lowers cost, eliminates waste and inefficiency, and improves healthcare delivery. This collaboration can help physicians develop new skills to lead future healthcare transformation while maintaining their most important focus: patient care. AM Howard Pitluk, MD, MPH, FACS, is Vice President, Medical Affairs & Chief Medical Officer; Mary Ellen Dalton, PhD, MBA, RN, is Chief Executive Officer; and Keith Chartier, MPH, who assisted with this article, is Communications Project Manager at Health Services Advisory Group. This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-11SOW-XC-022415-01

By connecting with each other to teach, learn, and implement evidence-based practices that better inform patients and involve them in their own healthcare, physicians can become leaders for a quality

Spring 2015 | AZMedicine 29


The Arizona Controlled Substances Prescription Monitoring Program: An Invaluable Tool for Physicians By Dean Wright Arizona legislation passed in 2007 established a Controlled Substances Prescription Monitoring Program (CSPMP) in Arizona. The Arizona State Board of Pharmacy (ASBP) oversees the CSPMP. Pharmacies and physicians who dispense controlled substances listed in Schedule II, III, and IV to a patient, are required to report prescription information to the Board of Pharmacy on a weekly basis. Arizona is now one of 49 states and one territory that have legislation establishing a monitoring program.

• Be designed to minimize inconvenience to patients, prescribing medical practitioners and pharmacies while effectuating the collection and storage of information.

The primary function of the ASBP is to provide a central repository of all prescriptions dispensed for Schedule II, III, and IV controlled substances in Arizona.

Under Arizona law, the CSPMP must: • Include a computerized central database tracking system to track the prescribing, dispensing and consumption of Schedule II, III, and IV controlled substances in Arizona, • Assist law enforcement in identifying illegal activity related to the prescribing, dispensing and consumption of Schedule II, III, and IV controlled substances, 30 AZMedicine | Spring 2015

• Provide information to patients, medical practitioners, and pharmacists to help avoid the inappropriate use of Schedule II, III, and IV controlled substances, and

The purpose of the CSPMP is to improve the State’s ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription controlled substance drugs in an efficient and cost effective manner that will not impede the appropriate medical utilization of licit controlled substances. The primary function of the ASBP is to provide a central repository of all prescriptions dispensed for Schedule II, III, and IV controlled substances in Arizona. Authorized persons such as DEA-registered physicians are strongly encouraged to request information from CSPMP to assist them in treating patients and identifying


and deterring drug diversion. Assuring confidentiality and the security of the data is a primary consideration for this program for all aspects to include data collection and storage, transmission of requests, and dissemination of reports. As of February 1, 2015, there are 8,352 medical practitioners and 4,262 pharmacists with authorized access to the database. As of the 4th Quarter of 2014, medical practitioners are using the database at the rate of over 5,157 queries per day and pharmacists are making over 3,548 queries per day. A.R.S. § 36-2606 requires each medical practitioner who is licensed under Title 32 and who possesses a DEA license to register with the CSPMP. Each DEA license should have an associated registration. There is NO fee to the practitioner for this registration. This registration includes: MD, DO, DDS, DMD, DPM, HMD, PA, NP, ND, OD, and DVM. Residents may register using the hospital DEA number and appropriate suffix. To register or renew go to this web site: https://www. azrxregistration.com/Login.aspx. If you do not know your CSPMP ID (Registration number) and the site says you are already registered, then call Dean Wright (see contact info below) or Cindi Hunter, Program Manager at 602-7712732 or email at chunter@azpharmacy.gov. Physicians and other required DEA-registered clinicians who wish to access the database should register for access as a prescriber at https://www.azrxreporting. com/Login.aspx. If you have any questions, contact Dean Wright, Prescription Monitoring Program Director at (602) 771-2744 or by email at dwright@azpharmacy.gov.

The Relationship Between Prescription Painkillers and Heroin Overdoses • In 2012, U.S. health care providers wrote 259 million prescriptions for painkillers (i.e. opioid or narcotic pain relievers including Vicodin, OxyContin, Opana, and methadone). • In Arizona, there were 82 painkiller prescriptions written per 100 people in 2012. • Higher prescribing of painkillers is associated with more overdose deaths. • In 2012, there was a sharp increase in heroin overdose deaths as well. One of the factors driving the increase in heroin overdoses appears to be widespread prescription opioid exposure and increasing rates of opioid addiction. • Research has found that approximately 3 out of 4 new heroin users report having abused prescription opioids prior to using heroin. This relationship between prescription opioid abuse and heroin is not surprising; heroin is an opioid, and both drugs act on the same receptors in the brain to produce similar effects. Source: CDC Vital Stats and Newsroom (http://www.cdc.gov/media/releases/2014/p1002-heroin-overdose.html).

Spring 2015 | AZMedicine 31


PDMP Report Card: Will You be at the Top of the Class? By Janet Weigel, Director of Education, Arizona Osteopathic Medical Association On December 10, 2014 the Arizona Prescription Drug Misuse and Abuse Initiative held a planning summit to review the results of a 24-month pilot program conducted in five Arizona counties: Yavapai, Pinal, Mohave, Greenlee, and Graham.

One of the five strategies employed in the program to fight prescription drug misuse and abuse was to Promote Responsible Prescribing and Dispensing Policies and Practices. The goals identified for this strategy were: • Encourage sign up and use of the Controlled Substance Prescription Monitoring Program (CSPMP) • Provide education and training and increase awareness of individual prescribing habits To achieve these goals, the Arizona Criminal Justice Commission and the Arizona State Board of Pharmacy developed the PDMP Report Card as a tool to convey pertinent information to prescribers on their prescribing habits for hydrocodone, oxycodone, carisoprodol, benzodiazepine, and other pain relievers. During the pilot program approximately 1,600 prescribers were individually sent a quarterly report card detailing 1. the number of prescriptions dispensed and 2. the total number of pills dispensed under their DEA number. The report included a comparison of the prescriber’s individual data to the average data for prescribers of their specialty type in the same county. The report card also contains the prescriber’s registration status with the PDMP. According to the Arizona Criminal Justice Commission, the following successes were identified from the pilot program: • from 2012 to 2014, Arizona saw a 20% reduction in the rate of youth prescription drug misuse and abuse

32 AZMedicine | Spring 2015


• there was a 109% increase in the number of prescribers signed up to use the CSPMP • there was an 84% increase in the number of queries actively being made to the CSPMP • rates of prescriptions and pills dispenses have decreased in all five prescription drug categories tracked (range = 2.3% to 16.3%) • pilot counties achieved a 28% decrease in opioid-related deaths, compared to a 4% increase in non-pilot counties Based on the success of the pilot program, the Arizona Prescription Drug Misuse and Abuse Initiative is expanding the program across the state. Pima and Maricopa counties will be online by the end of the second quarter of 2015. All other Arizona counties are expected have some kind of program in place by the end of 2015. The PDMP Prescriber Report Card is also being expanded to convey additional information: • # of patients who received 100 mg or more Morphine Equivalent Daily Dose (MEDD) of prescription narcotics • # of patients at risk for a dangerous drug combination involving the five monitored drugs • # of patients prescribed opioids/this prescriber • # of patients going to more than 5 prescribers and 5 pharmacies In 2015, if you aren’t receiving one already, your quarterly Prescription Drug Monitoring Project (PDMP) Report Card will be sent to you by the Arizona CSPMP. To get the most of the data, be sure that you are registered as a prescriber with the CSPMP (as required by Arizona statute), sign up to access the data base (you may identify a designee to access the data base), and periodically request a report on each of your patients, especially if they are being prescribed one or more controlled substances. Your participation, awareness, and vigilance can aid in reducing the incidences of prescription drug misuse and abuse. For more information about the CSPMP contact Dean Wright, RPh, CSPMP Director at (602) 771-2744 or dwright@azpharmacy.gov. For questions about the Arizona Prescription Drug Misuse and Abuse Initiative visit www.azcjc.gov/acjc.web/rx or email Shana Malone at smalone@azcjc.gov.

Ten Reasons Why You Should Use the Prescription Drug Monitoring Program Data Base

1 2 3 4 5 6 7 8 9 10

Easier to use – prescribers can now identify a designee to access the data base More accurate – 24-hour reporting by dispensers Alerts prescribers to patients at highest risk of abuse and overdose Identifies criminal prescribers and clinics – “pill mills” Detects doctor shoppers Monitors and detects geographic areas where increased abuse/misuse is occurring Recognizes potential need to refer a patient for substance abuse treatment Reduces illicit acquisition and diversion of prescription drugs Limits your liability as a prescriber Saves lives!

A version of this article appeared in the AOMA Digest, Winter 2015, Vol. 30 No. 1.

Spring 2015 | AZMedicine 33


Prevention is preferable to a cure By Todd Levine, MD The proper treatment of patients can take on a variety of challenges, but in all things physicians are guided by the Hippocratic Oath that includes the phrase, “I will prevent disease whenever I can, for prevention is preferable to cure.” There are approximately 116 million Americans diagnosed with chronic, non-malignant pain. It is the most common reason patients seek medical care, resulting in $635 billion annually in both medical costs and decreased work productivity. Treating these patients in a manner that alleviates their pain yet protects against untoward consequences, such as abuse, has offered limited options. The need to consider “prevention” of abuse while treating pain has left many physicians in a Catch-22.

of prescribed medication by others than the patient, while properly treating chronic pain patients. The pharmaceutical industry has been equally involved in the search for a solution. The goal has been to produce a drug that is safe and effective for the intended population yet would safely deter abuse by potential abusers and is economically feasible. Finally, we have a technology called Abuse Deterrent Formulations (ADF) that removes the ability for manipulation of these medications, thereby significantly reducing the ability for abuse. This technology presents no change in the efficacy of the medication for the treatment of pain but the abuse potential is extremely diminished.

The need to consider “prevention” of abuse while treating pain has left many physicians in a Catch-22.

Those who are diagnosed with non-malignant chronic pain need, and deserve, to be properly medicated in order to enjoy their activities of daily living to the best of their ability. For most patients, it is a quality of life issue and the relief offered through practitioner provided prescription medication is essential. Opioid based analgesics, in pill form, are the primary source of their relief.

However, drug abusers are commonly manipulating opioids by crushing, grinding, or melting the tablets then either injecting or sniffing the drug. The rapid absorption offers a quick “high” and gives the abuser an immediate, greatly increased blood level of the drug versus that achieved by ingesting the pill through swallowing. The Center for Disease Control reports 46 people die each day from an overdose of prescription pain killers. Additionally, there is a growing epidemic of heroin use. In far too many cases this started with the abuse of prescription opioids and advanced to the less expensive and easier obtained opiate, heroin. Benign beginnings that lead to a catastrophic end. Physicians must guard against drug-seeking behavior in patients for the sake of non-medical needs or the abuse 34 AZMedicine | Spring 2015

Within ADF technology there are a variety of formulations that deter abuse. In one type, if the medication is crushed, ground or melted the transmission of the opioid effect is blocked, rendering it without the desired result to the abuser. In another, the pill is coated in a substance that prevents the extraction of the interior of the pill, the opioid within, disallowing melting or crushing. The statistics on non-malignant chronic pain and opioid abuse demand a response to the need of physicians to properly treat patients with chronic pain, while preventing intentional abuse. Abuse Deterrent Formulations should be readily available to decrease clinical concerns while providing patients the analgesia required. The use of ADF technology in treating and prescribing medication allows physicians the ability to treat patients and maintains the sanctity of our pledge and the belief that “…prevention is preferable to cure.” Todd Levine, MD is co-director of the neurophysiology department at Banner Good Samaritan Medical Center and a clinical assistant professor at the University of Arizona in Neurology. This op-ed first appeared in the Arizona Capitol Times, February 5, 2015, and is reprinted here with permission of the Arizona Capitol Times editor. The original appears online at http://azcapitoltimes.com/news/2015/02/05/ prevention-is-preferable-to-a-cure/.


Supervising Editor Bruce Bethancourt, MD

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AzMedicine is published four times a year by the Arizona Medical Association (ArMA) for Arizona Physicians. It contains articles of interest to the medical community, covering socio-economic, political and scientific information. The views and opinions expressed are the authors’ and do not reflect those endorsed by ArMA. ArMA does not guarantee or endorse the products or claims advertised.

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MICA_AzMed02'15_Layout 1 2/13/15 9:52 AM Page 1

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