Practiced Based Research Networks: Promoting a Culture of Innovation Through PCMH Transformation

The Military Health System (MHS) has a distinguished history of technological innovation. Consider, for example, the Composite Health Care System (CHCS), the Armed Forces Health Longitudinal Technology Application (AHLTA) and, more recently, secure messaging technology. It may be argued, however, that the benefits of technological innovations in the MHS are not fully realized due to variability in their implementation and use. Often, the implementation of technological innovations does not consider business process flows and therefore lacks the context necessary to enable successful adoption and uptake.
With regard to advancing MHS initiatives such as the Quadruple Aim, innovations already exist. For example, the Patient Centered Medical Home (PCMH) is an innovative model of health care delivery that is directly associated with the Quadruple Aim initiative. The following are examples of PCMH activities that align with MHS’ Quadruple Aim objectives: • Conducting comprehensive health assessments (which aligns with the readiness objective); • Using data for population management (which aligns with the population health objective); • Measuring patient/family experience (which aligns with the experience of care objective); and • Monitoring data on utilization that affects health care costs (which aligns with the cost objective).
In addition, technological innovations will be available to facilitate the MHS’s transformation to the PCMH model. Specifically, PCMH team support dashboards are being developed as decision support tools that serve up clinical information at the point of care delivery. These dashboards intend to help clinical care teams:

  1. Ensure active duty patients are ready to deploy;
  2. Manage the chronic care and preventive service needs of their patient population;
  3. Enhance patients’ experience of care; and
  4. Lower per capita cost by reducing the number of ER visits, minimizing the number of hospitalizations, and actively promoting prevention. However, as alluded to earlier, technological innovation is necessary, but insufficient to implement a comprehensive change strategy. For example, implementing a technological solution to serve up actionable information to the provider and PCMH teams must consider where in the process flow clinical information is needed.

Proposal To that end, Practice Based Research Networks (PBRNs) are proposed for “supporting quality improvement within primary care practices and the adoption of an evidence-based culture in primary care practice”. Practice Based Research Networks are groups of medical practices that are united by a shared commitment to better understanding the health care delivery process that happens daily in their practice settings. Conceptually, they enable practitioners to rigorously and scientifically study the process of care delivery, including the manner in which diseases are diagnosed, treatments are initiated, and chronic conditions are managed. In other words, PBRNs provide the infrastructure for applied laboratories that expand the science base of clinical care through systematic inquiry in actual settings. These networks may affiliate with academic or professional organizations to study issues or questions that are relevant to their practices. The PBRN approach capitalizes on the knowledge and experience of practitioners to target issues or questions that can improve the local primary care practice. Examples of types of PBRN research include studies in comparative effectiveness research: • Treatment of common diseases and symptoms, prevention and early diagnosis; • Organization and clinical systems; • Continuity and coordination of care; • Clinical decision support; and • Impact of decisions made by patients about health care and health practices for themselves, their families and their communities.3 In this way, PBRNs are as essential to advancing the scientific understanding of medical care as bench laboratories are to advancing knowledge in the basic sciences. Because these practices are grouped together in a network, they collaborate, cooperate, and share experiences and insights. According to the Agency for Healthcare Research and Quality (AHRQ), leaders of PBRNs are increasingly considering their networks as learning organizations “where clinicians are are engaged in reflective practice inquiries, and where clinicians, their patients, and academic researchers collaborate in the search for answers that lead to the improved delivery of primary care”.3 As a learning organization, PBRNs enable both self-discovery and cross-fertilization of the experiences and insights of practitioners engaged in the actual work flows. The utilization of PBRNs inherently incorporates the context necessary to facilitate the PCMH transformation by: • Informing policy to help guide successful implementation and uptake; • Understanding resource needs (including personnel and training as well as equipment); and • Understanding practice requirements and patterns. In essence, PBRNs are effective for developing and sustaining a culture of learning and innovation that can guide the implementation and use of the PCMH model of care to influence outcomes associated with the Quadruple Aim initiative. Likewise, the PBRN approach can and should be used to guide other MHS initiatives such as the MHS Clinical Quality Management Program to better understand and improve upon the delivery of healthcare.

Method The success of PBRNs prompted an Institute of Medicine committee on primary care to recommend continued support to expand practice based primary care research networks. Since 2000, the Agency for Healthcare Research and Quality (AHRQ) has become an important source of funding and support for primary care research networks. In addition to funding opportunities, AHRQ has a national resource center to support PBRNs. Accordingly, a staff of experts at the PBRN Resource Center can provide consultative services, informational resources, group learning experiences, and research tools to PBRNs registered with AHRQ. Although the US Army Chief Medical Information Office (CMIO) will oversee this demonstration project, there will be close collaboration and consultation with AHRQ and the PBRN Resource Center.
Objective Toward the objective of supporting and advancing elements of the Quadruple Aim, this proposal advocates the implementation of PBRNs to scientifically study the transformation to the PCMH model of care delivery as a catalyst for MHS's strategic goals.

Selection of Practices The composition of the PBRN will consist of 15 (or more) practices representative of healthcare in the MEDCOM. It is important to note that criteria to ensure “representativeness” can include characteristics such as size, geographic location, or specialization. For the purposes of this demonstration project, a practice is defined as a medical home, or PCMH team. Accordingly, three Army Military Treatment Facilities (MTFs) from different geographic locations will be recruited for participation. From each MTF, five PCMH teams will be identified for inclusion in the PBRN demonstration project. The PBRN will be registered with AHRQ and the PBRN Resource Center for additional support and guidance. Implementation of the PBRN The US Army CMIO will coordinate and oversee activities of each practice included in the PBRN. Each MTF will require a point-of-contact (POC) responsible for logistics and administrative functions. Responsibilities of the POC include, but are not limited to: • Assisting with obtaining ethical oversight from the appropriate Institutional Review Board (IRB); • Obtaining local leadership support and approval and providing regular briefings; • Working with the local PCMH team to: o identify key issues or research questions for study; o design the data collection and analyses protocols; o interpret the analytic results; and o determine recommendations based on the study findings; • Working with the US Army CMIO team in terms of: o identifying key issues or research questions for study; o designing the data collection and analyses protocols; o interpreting the analytic results; and o determining recommendations based on the study findings; • Working with POCs from other practices in the PBRN; and • Providing updates to AHRQ and seeking assistance from the PBRN Resource Center as needed.
The US Army CMIO will work with the POCs from each MTF to coordinate the research design and implementation among their local practices. Web-based services (e.g., Sharepoint or will be used to cross-fertilize the lessons and insights learned at the practice level. Thus, the PBRN methodology functions to create local knowledge and experience and to cross level that insight with other sites and practices in the network.

POC Recruitment The POC from each MTF should have knowledge of the local business processes and requisite skills and interest in the study of primary care practices, such as a clinical workflow analyst (CWA). It is the recommendation of this proposal to purchase a percentage of the CWA’s time to ensure dedicated resources for this effort rather than simply add these responsibilities to their current duty list (see Table 1 below).

Timeframe The most current fiscal year (e.g., October 2013 – September 2014)

Suggested Timeline • Month one: register with AHRQ and the PBRN Resource Center; identify MTFs for inclusion; • Month two: identify/recruit POCs; conduct introductory teleconference to brief POCs and begin identifying PCMH teams for inclusion (continue with weekly meetings); begin working on IRB submission; • Months three and four: identify research question to study; begin development of research design; continue with IRB submission and approval; ensure POCs have proper training (e.g., HIPAA); ensure data use agreements are obtained, if necessary; • Month five: develop/refine research design, including data collection and analyses; • Months six – nine: work with PCMH teams to collect and analyze data; • Months 10 – 12: Interpret analyses; develop recommendations
Estimated Cost This demonstration project relies on resources already utilized in daily practice. The primary costs incurred with this proposal reside in the procurement and utilization of a local POC for each of the three MTFs, and training and facilitation for the implementation. Assuming an annual salary and benefits package of $90,000 for a clinical workflow analyst (CWA), cost can be estimated depending upon the percentage of time purchased for each POC. Table 1. Cost Estimates Based on Average Annual Salary & Benefits for CWA = $90,000. Percentage of time Estimated Cost for one CWA Estimated Cost for three CWAs 10% $9,000 $27,000 20% $18,000 $54,000 30% $27,000 $81,000 40% $36,000 $108,000 50% $45,000 $135,000 60% $54,000 $162,000 70% $63,000 $189,000 80% $72,000 $216,000 90% $81,000 $243,000 100% $90,000 $270,000

Overall coordination and oversight will require .5 FTE of personnel already assigned to the BI Division of the US Army CMIO office.
Travel expenses will require one two-three day visit by two subject matter experts (SME’s) to each MTF for training and on-site facilitation.

Academic Affiliation It is important to note also that the PBRN approach can be augmented with an academic affiliate. Accordingly, projected costs can be offset by partnering with an academic program such as the Baylor residency program. Such a partnership not only provides assistance in PBRN activities such as data collection and analyses, it also offers academic partners applied research experience and may assist in fulfillment of academic requirements, such as Theses.

Possible Study Topics The following are examples of PCMH topic areas that are relevant to the Quadruple Aim initiative and that can be studied by the PBRN approach:
• Enhancing access and continuity of care o Same day appointments o Percentage of appointments with the assigned PCM and/or team o Use of secure electronic media • Identifying and managing patient populations – for example, patients: o In need of deployment related services to ensure soldier readiness o With selected chronic care or preventive service needs o Who over and/or under utilize the system o High risk conditions (e.g., eligible for case management) o With medication management needs (e.g., opioids, polypharmacy) • Tracking and coordinating care – identify: o Overdue lab results o Abnormal findings (lab, imaging, etc.) o Patients for transitions of care (e.g., ER visits, hospitalizations) • Measuring and improving performance o Chronic care/preventive service measures o Utilization measures that affect health care costs o Patient/family experience In practice, the PCMH teams participating in the PBRN will identify a relevant topic or issue for the pilot project (e.g., how can the PCMH model of care ensure specific deployment related services are conducted for soldier readiness?). Contrary to traditional health services and epidemiological research that examines trends or snapshots of performance, the PBRN approach facilitates a better understanding of the factors (organizational, individual) that actually drive performance. Whereas the PCMH model and technological dashboards can facilitate healthcare delivery efforts, the PBRN methodology helps establish an environment that enables those strategies to work better. Accordingly, PBRNs are like BAE Systems….they don’t implement PCMHs, they make the implementation better!

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