CAPP Physician Group: HARVARD VANGUARD
Project: CHRONIC ILLNESS CARE PROJECT

Summary: Physicians and other clinicians at Harvard Vanguard use medical information to integrate population management and chronic care programs into primary care with positive results in improved diabetes quality measures. Early management of such chronic illnesses will result in better lives for their patients and cost savings for employers.

Harvard Vanguard Medical Associates of greater Boston, Massachusetts, has developed new programs to address proactively the needs of patients with chronic illnesses. Their goal is to improve early management of chronic illnesses to delay the onset of long-term complications.

To accomplish this, Harvard Vanguard has leveraged its electronic medical record and extensive patient data warehouse to create the informatics support to integrate novel care management processes* into the frontlines of primary care:

1. Population management utilizes clinical informatics to facilitate data-driven continuous chronic illness care improvement.

2. Systems-based practice allows for coordinating resources effectively to reliably deliver, high quality chronic illness care.

3. Planned chronic illness care includes-a series of proactive patient visits dedicated to chronic illness management where clinicians and the nursing staff address comprehensive patient needs, including evidence-based care and promotion of patient self-management through behavioral counseling.

For example, to support population management, every primary care clinician receives a quarterly set of patient-level “dashboard” reports of all diabetics in their practice, including their clinical, pharmaceutical, and care utilization data. Clinicians can sort through the data rapidly to identify gaps in care in order to generate a specific action plan involving the patients who compose those gaps. To support planned care, the electronic medical record is used to create bundled order sets for routine follow-up diabetic visits. In addition, a designed progress note template has been created that allows for each chronic disease planned visit to promote comprehensive care.

Harvard Vanguard began the design and development of these interventions in 2003. When looking at the change in diabetes quality of care from 2004 to 2006, the overall diabetes composite quality measures improved consistently.

*Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4

For more information about this project or for an interview with Dr. Joe Kimura, please contact Marci Sindell at (617) 559-8323.

Integrating Services for Low-Income Seniors Shows Health Care Benefit, by Claire Sowerbutt, Contributing Writer, MedPage Today, December 11, 2007.

INDIANAPOLIS, Dec. 11 -- For low-income seniors, the likelihood of providing the recommended standard of health care services could be enhanced by integrating home-based and institutional services, found researchers here.

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“From High Tech to Soft Touch: The Everett Clinic uses innovative ways to control health care costs,” by Bryan Corliss, Washington CEO, November 26, 2007.

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“CAPP’s 35 MSMGs [multispecialty medical groups] share a common vision as learning organizations dedicated to the improvement of clinical care. Their features include physician leadership and governance; commitment to evidence-based care management processes; well-developed quality improvement systems; team-based care; the use of advance clinical information technology; and the collection, analysis, and distribution of clinical performance information. These features are congruent with the [Institute of Medicine’s] recommendations on key elements needed to redesign delivery systems.”

From Chapter 5, “Developing the Test Bed—Linking Integrated Service Delivery Systems: Council of Accountable Physician Practices,” by Michael A. Mustile, MD. The Learning Healthcare System: Workshop Summary (IOM Roundtable on Evidence-Based Medicine), edited by LeighAnne Olsen, Dara Aisner, and J. Michael McGinnis, National Academies Press, 2007.

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“A shift from the current care model to a more coordinated care model centered on primary care is one potential way to help stave off the healthcare dilemma.”

“It's too expensive to be a primary-care doctor,” by Debra A. Geihsler, president and CEO of Harvard Vanguard Medical Associates & Atrius Health. Boston Globe, July 25, 2007.

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