Guest Commentary: Systems Engineering for Population Health

James F. Pelegano, MD, MS
Program Director
Master of Science in Healthcare Quality and Safety/Management

This is the first in a series of blog posts previewing the Twelfth Population Health & Care Coordination Colloquium, taking place February 27-29 at the Philadelphia Downtown Marriott Hotel.

When we use the phrase “systems engineering” it is not unusual to immediately jump to a manufacturing context. However, the operational approach to population health requires that we engineer systems that bring us a measurement of the health outcomes within a population so that we can more appropriately select our interventions and construct policies that allow us to standardize and analyze our care of specific populations.

The “systems” of which we speak involve multiple components that work together to achieve the goals of evidence based high quality care. During the preconference presentation, Advanced Applications in Population Health, of the Population Health and Care Coordination Colloquium we will be using a defined population, neonates, to illustrate these components.

In order to provide an operational understanding of the basic principles, we will use actual clinical cases and data to illustrate how IT systems, international benchmarking, data analysis, outcomes trending, standardized care and focused peer review all combine to create these essential clinical systems. By looking at a specific population we can better understand how these various components work in coordination. We will also look at the interfaces of the various components to better understand what is required from each of the specific parts of the system with respect to information flow and to overcoming specific barriers to success.

The focus on a well-defined population will allow us to be very concrete in our approach and will provide a basis for approaching other well defined populations.

Thus, the learning will be transferable to the development of other clinical systems within these other populations. The participant will leave with an understanding of how these systems are constructed and operationalized at the population/provider interface.

It is only by engineering at this population/provider interface that we can be successful in translating theory into practice and thus impact the determinants that influence the outcomes distribution in the population.

The Twelfth Population Health & Care Coordination Colloquium will be February 27-29 at the Philadelphia Downtown Marriot Hotel. To register, or for further information, www.PopulationHealthColloquium.com, or call 800-503-7439.

Guest Commentary: Third Annual Schweitzer Day of Service – North Philadelphia

Nicole Cobb Moore, MA
Greater Philadelphia Program Director
Albert Schweitzer Fellowship

"I don't know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve." - Albert Schweitzer

The Albert Schweitzer Fellowship (ASF)’s Greater Philadelphia Schweitzer Fellows Program held its Third Annual Day of Service on Saturday, January 21st at the Zion Baptist Church’s Educational Annex/Community Center in North Philadelphia.

Thirty-two volunteers—including current and potential Schweitzer Fellows, friends, family members, and 10 students from Youth Build Philadelphia Charter School—braved the snowy weather to scrap, sand, and repair the church’s fellowship hall (a space that helps to facilitate the church’s health and social service programming).

From replacing broken light bulbs to painting the walls with paint generously donated by several local businesses, the volunteers worked from 10 am to 4 pm to revitalize the 49’ by 59’ hall.

The volunteers’ efforts were lauded by Zion’s Cornelius D. Pitts, PharmD, who serves as a site mentor for current Schweitzer Fellow Lawrence Onishi (who is working to expand the church’s health literacy offerings).

“I just want to directly thank you for your time, compassion and dedication in providing such heartfelt assistance,” Pitts told the volunteers. “‘Service with joy’ is the phrase that came to mind for me … and that is what we are all called to. I suspect that [this service day], although admirable, is only a slight indication of the path you've chosen to follow in your lives, as is the mission of the Albert Schweitzer Fellows program. The energy you expend in these efforts will inspire others to do the same... and that is how the world will be changed for the better.”

For more information about the Greater Philadelphia Schweitzer Fellows Program, visit www.schweitzerfellowship.org/philadelphia.

For photos of the service project, go to http://www.facebook.com/media/set/?set=a.10150541197031728.376273.72710636727&type=3

Population Health Colloquium 2012 in Philadelphia

The 2012 Population Health Colloquium will be the biggest and the best ever!! All of the major policy leaders in our field will be coming to Philadelphia from February 27through the 29th at the Marriott Convention Center Hotel. Outstanding speakers including Mike McCallister from Humana, Peggy O Kane from the NCQA, Richard Baron from the CMS Innovation Center and Ed Wagner from the Group Health Cooperative will headline the program. We will review the impact of health reform on our delivery system and the push toward practicing a different kind of medicine--namely, population based care. In addition, at two special pre conference workshops,key faculty from the Jefferson School of Population Health will be presenting on topics such as "Population Health as a Foundation of Health Reform" to "The Myth of Consumer Choice-- What will take its Place?". Finally, at a unique Sunday Night Book And Author Event, just prior to the Conference on February 26th, five nationally prominant authors will be speaking about their award winning books including DAVID ANSELL from Rush in Chicago discussing his book, COUNTY--Life and Death and Politics at Chicago's Public Hospital. For more information log onto www. PopulationHealthColloquium.com. I sure hope to see you there!!! DAVID NASH

Guest Commentary: Vaccine Hesitancy Leading to Lower Immunization Rates

Ruth S. Gubernick, MPH

I am the proud grandmother of a 5-month-old granddaughter whose parents are having her immunized by her pediatrician, according to the Recommended Immunization Schedule, approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP).

Recent articles and a national survey are reporting, however, that at least one out of every 10 parents in this country are not following this recommended schedule and are opting out of immunizing their children either on time or at all. Most of these parents are college-educated professionals. Some of these children will be the playmates of my granddaughter.

Vaccine hesitancy is resulting in lower immunization rates in the U.S. today. This year alone, we've had outbreaks of whooping cough and measles in several U.S. communities. Those diseases are only a plane ride away. Several people incubating measles flew into Newark, NJ earlier this year coming in contact with young families in several communities. The un/under-protected infants and children in those communities without high immunization rates or community/herd immunity were especially at risk of disease.

Parents don't want the government or anyone else to make those decisions for their children. I get that. But the problem is where they are choosing to get their information about vaccine safety. It's often the talking heads on TV and Internet bloggers with misinformation, rather than science-based research. I'm in favor of individual rights but their decisions for their own children can adversely impact my granddaughter, who is not yet old enough to be protected against diseases such as measles or chickenpox.

As a public health professional, I see immunizations as a societal responsibility, to protect those who are too young or otherwise unable to receive these recommended childhood immunizations against 14 potentially life-threatening vaccine preventable diseases. Parents who hold "pox parties" or share "lolly-pox" with their infected child's saliva or swabs dabbed with fluid from their child's pox with other families, rather than have their children immunized, make me crazy. Natural disease is not less risky than a vaccine!

I recently piloted an online course that I designed and built for the JSPH Teaching/Learning Seminar required for my doctoral program. It is about immunizations and targets college-educated professionals who are new parents. My students reported that video clips of parents telling their own stories had the most impact on them. I introduced the course with How safe are we? The Role of Vaccines in Protecting your Community ( http://www.youtube.com/watch?v=hsDU35G477E&feature=youtu.be ). It opens with a mom sharing how she felt about unknowingly infecting her newborn with Pertussis. Share these stories with the families that you care for and care about who may be vaccine hesitant. As a grandparent and population health advocate and student, I thank you.

Ruth Gubernick is a JSPH doctoral student.

What a year!!!

As I reflect on 2011, from a health policy perspective, it has been quite a year indeed. Berwick is out, ACOs are in, and costs continue to rise. Employers are trying everything and corporate wellness and prevention is the "new green". The lines separating payers, providers and purchasers are blurring every single day as insurance companies buy doctor practices and hospitals too!! The New England Journal says Disease Management doesn't work and everyone believes one study based on the sickest Medicare patients only. It is increasingly difficult to separate out the "truth" from the background noise, especially as the noise gets louder and louder.

Personally, I am really looking forward to 2012 and the ongoing struggle to make health care more accountable, transparent, safer and more cost effective. I am confident that the Jefferson School of Population Health will continue to provide leadership in its research, teaching and dissemination agenda. Our journals, this BLOG, our Medpages column, our national conferences, continue to resonate with the key opinion leaders in healthcare across the nation.

I hope that you will continue to turn to us for informed opinions and solid evidence too about what is working and what is not. One thing surely still remains the same regarding the reform efforts and that is of course " No Outcome--No Income". I am convinced that the future belongs to groups that can make this pithy statement a reality for everyday practice. We are always interested in your views too. DAVID NASH

Guest Commentary: CMS Continues to Raise Stakes on Quality Measurement

This is the third in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Valerie P. Pracilio, MPH, Project Manager for Quality Improvement
and Bettina Berman, RN, Project Director for Quality Improvement

Measuring quality of care in the inpatient setting has been a staple of the healthcare environment for several years. Hospitals are penalized financially if they do not report data to the Centers for Medicare and Medicaid Services (CMS) on certain conditions, so solid measurement criteria is a necessity.

CMS’s desire to increase accountability at the provider-level created a need to assess quality in outpatient settings. In 2006, a governmental mandate led to the establishment of the Physician Quality Reporting System (PQRS) to incent eligible professionals who satisfactorily report data on quality measures for services provided to Medicare beneficiaries. Since then, JSPH has been collaborating with Quality Insights of Pennsylvania (QIP) on the development and maintenance of the measures included in the PQRS program.

Measurement development is a rigorous process that must be supported by solid evidence and must also consider feasibility of application in practice. Through our engagement with the QIP, our team has supported this process through evidence gathering and grading. A Technical Expert Panel (TEP) established for each measure also works with QIP to discuss feasibility of measure application. JSPH plays a part in engaging relevant experts to serve on the panel and presents the evidence to support their decisions. Once the measure development process has concluded, the measures are submitted to the National Quality Forum (NQF) for endorsement and broadly disseminated.

At Thomas Jefferson University, the faculty practice plan, Jefferson University Physicians (JUP), has participated in the PQRS program since its inception. Under the leadership of Dr. David B. Nash, the committee that oversees JUP’s performance improvement activities, the JUP Clinical Care Subcommittee (CCS), decided that participation in this program would be valuable to advance quality of care. A strong collaboration between the JUP Performance Improvement Team and JUP administration led to successful implementation of the PQRS program in all practices. The team works closely with practice representatives to select measures for submission and provides ongoing education and support for the practices. As a result, JUP has successfully increased physician participation and incentive payments over the past four years since the start of the program.

More accountability is on the way. CMS plans to move from pay for reporting to pay for performance. Beginning in 2013, CMS will publish PQRS data on the Physician Compare website for providers who report on quality measures through the Group Practice Method (GPRO). In 2015, the stakes will be raised even higher when providers’ Medicare payments are adjusted downward if they do not participate in the PQRS program. The question remains – will demand for provider accountability benefit Medicare beneficiaries?

As always, we are interested in your comments.

Guest Commentary: Physician Profiling in Emilia-Romagna Italy: A Tool for Quality Improvement

Vittorio Maio, PharmD, MS, MSPH,
Associate Professor
and Valerie Pracilio, MPH, Project Manager
for Quality Improvemement
Jefferson School of Population Health

This is the second in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Assessment is part of our daily lives. In school, we apply for admittance; in employment, we are screened before being hired, and once we’re “in,” we are regularly evaluated to ensure that we are performing at a level deemed appropriate. In the Italian Healthcare System a similar approach is being used to engage primary care physicians in quality. Performance data presented to physician teams is the first step in a profiling process. Not only does this help raise their awareness about the level of care they are providing, but it also engages them in discussions with their peers about what they can do to improve.

By definition, physician profiling is an analytic tool used to compare physician practice patterns across quality of care dimensions (American Academy of Family Physicians). The benefit is that it raises provider awareness of quality through feedback to stimulate improvement.

In Italy, primary care, provided by general practitioners (GPs), is the foundation of the Italian National Health Service, which maintains universal coverage to all citizens either free or at minimal charge at the point of service. Traditionally, GPs have worked in solo practices. However, in the last ten years, in an effort to increase coordination of care, the Italian National Health Service has introduced substantial reforms seeking to encourage collaborative arrangements among GPs. In order to build on earlier national reform, the Emilia-Romagna region (a large region located in northern Italy with a population of about 4.6 million inhabitants) passed a law in 2004 that required GPs to join a Primary Care Team (PCT).

In a PCT, GPs, many of whom are in solo practice, act in full autonomy, but are part of clinical networks designed to provide patients with integrated delivery of healthcare. Specifically, in a PCT, GPs are mandated to collaborate and share information, and by means of clinical governance, to engage in improving the quality of healthcare services provided to patients.

To this end, using the regional healthcare administrative database, the Emilia-Romagna region and Thomas Jefferson University began a collaboration to provide PCTs with information about the quality of services delivered to their patients via PCT profiles. GPs discuss the PCT profile data they are presented with their colleagues in their PCT and initiate PDSA cycles of improvement to make changes to their practice accordingly. Through a collective agreement with the region, GPs receive incentives to participate in the activity.

In the U.S., where the mission is not unified as it is in Italy, the focus has been on paying for performance rather than participation. There is something to be said for the focus on participation that has been demonstrated in Italy to invite physicians into the conversation about quality and actively engage in improvement. In the current U.S. healthcare environment, the stakes are being raised and soon the incentives for improving will turn into disincentives for not meeting standards.

Should we be focused on engaging physicians in quality through a non-punitive approach such as the one our colleagues in Italy are using, or continue to expect physicians will meet quality goals if incentivized? We’re interested in your thoughts.